1222 Jasmine St HENS19-0004 it_t,„,,, BACKYARD HEN PERMIT APPLICATION 1 Z (( Z, i(
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��� �,��` City of Atlantic Beach
;_-_, :, Community Development Department
-' 800 Seminole Road Atlantic Beach, FL 32233 FOR INTERNAL OFFICE USE ONLY
'�:o;u V' (P) 904-247-5800 PERMIT# �� (-NSI�j 0004
APPLICANT/PROPERTY INFORMATION
NAME J(I, 'f5 77 too K5 EMAIL f?RUD/<SCl17Z,5i y' ( 6 &' Y411oc2.00%11
ADDRESS /2,21_ i sl#'l/,LC S% CITY 'j a 1 g Cli4 STATE FL ZIP CODE JZ a 33
PHONE# CELL# ,'O -, 1?? -520 VV 2 OWNER ❑ LEGAL AUTHORIZED AGENT
TENANT INFORMATION (if applicable)
NAME PHONE#
EMAIL CELL#
BACKYARD HEN PERMIT APPLICATION PACKAGE CHECKLIST
ITEMS REQUIRED FOR APPROVAL:
ditional information may be required,depending upon circumstances unique to individual applications 0\
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BACKYARD POULTRY SEMINAR CERTIFICATE: From the Duval County Agricultural Extension Office
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CI PASSED INSPECTION OF PROPERTY: Including coop/pen size,construction,location and screening \1i
El APPROVAL LETTER FROM HOA: If applicable N \1/
111 NUMBER OF HENS TO BE KEPT ON PROPERTY 3imit of 5
❑ PAYMENT OF$25.00: To be paid upon satisfaction of the above requirements
I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS APPLICATION IS CORRECT TO THE BEST OF MY KNOWLEDGE. I
HEREBY ACKNOWLEDGE THE TERMS OF ORDINANCE 95-17-113 AND SWEAR TO FOLLOW ALL REQUIREMENTS THEREIN.
FURTHER,I HEREBY GRANT PERMISSION FOR THE CITY OF ATLANTIC BEACH TO ENTER THE PROPERTY LISTED ABOVE FOR THE
PURPOSE OF INPSECTING FOR COMPLIANCE AND AGREE TO REMOVE ALL HENS AND ASSOCIATED STRUCTURES UPON THE
TERMINATION OR EXPIRATION OFA TEMPORARY PERMIT AND/OR THIS ORDINANCE.
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SIGNATURE OF APPLICANT PRINT OR TYPE NAME DATE
Signed and sworn before me on this 1 day of J p 0 ,Z (Q 1 by State of
County of Ib •
Identification verified: i Z ^ I V I -- S4 ^ (J ►% — (-
Oath Sworn: ❑ Yes ❑ No , _
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Notary Signature
My Commission expires
~ .; TONT GINDLESpERGER
`” :,; MY COMMISSION#GG 353178
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;''!��; EXPIRES:October 6,2023
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05 BACKYARD HEN PERMIT APPLICATION 07.16.2019
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