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510 Royal Palms Dr FNCE20-0011 6' FENCE WALL OR BARRIER PERMIT PERMIT NUMBER ; �, CITY OF ATLANTIC BEACH FNCE20-0011 r 800 SEMINOLE ROAD ISSUED: 2/25/2020 - �°xi9r v ATLANTIC BEACH. FL 32233 EXPIRES: 8/23/2020 " MUST CALL INSPECTION PHONE LINE (904) 247-5814 BY 4 PM FOR NEXT DAY INSPECTION. ALL WORK MUST CONFORM TO THE CURRENT 6TH EDITION (2017) OF THE FLORIDA BUILDING CODE, NEC, IPMC, AND CITY OF ATLANTIC BEACH CODE OF ORDINANCES . ALL CONDITIONS OF PERMIT APPLY, PLEASE READ CAREFULLY. NOTICE: In addition to the requirements of this permit,there may be additional restrictions applicable to this property that may be found in the public records of this county, and there may be additional permits required from other governmental entities such as water management districts, state agencies, or federal agencies. JOB ADDRESS: PERMIT TYPE: DESCRIPTION: j VALUE OF WORK: 510 ROYAL PALMS DR FENCE WALL OR BARRIER FENCE 6' FENCE $0.00 TYPE OF REAL ESTATE I ZONING: BUILDING USE SUBDIVISION: CONSTRUCTION: I NUMBER: GROUP: 171514 0000 ROYAL PALMS UNIT 02A3.00 COMPANY: ADDRESS: CITY: STATE: ZIP: OWNER: ADDRESS: 1 CITY: STATE: ZIP: OGIN JACK F 6101 RAINTREE RD JACKSONVILLE FL 32277 WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT. LIST OF CONDITIONS Roll off container company must be on City approved list. Container cannot be placed on City right-of-way. 1 PUBLIC WORKS ON SITE RUNOFF INFORMATIONAL Notes: All runoff must remain on-site during construction. 2 PUBLIC WORKS ROLL OFF CONTAINER INFORMATIONAL Notes: Roll off container company must be on City approved list. Approved list can be obtained at the Building Department at City Hall. Roll off container cannot be placed on City right-of-way. Issued Date: 2/25/2020 1 of 2 �s. , FENCE WALL OR BARRIER PERMIT PERMIT NUMBER ass ,.,,, CITY OF ATLANTIC BEACH FNCE20-0011 �` "" ISSUED: 2/25/2020 800 SEMINOLE ROAD —an U ATLANTIC BEACH. FL 32233 EXPIRES: 8/23/2020 3 PUBLIC WORKS RIGHT OF WAY RESTORATION INFORMATIONAL Notes: Full right-of-way restoration,including sod,is required. 4 PUBLIC WORKS RUNOFF INFORMATIONAL Notes: All runoff must remain on-site. Cannot raise lot elevation. 5 PUBLIC WORKS FENCING REMOVED INFORMATIONAL Notes: All old fencing and debris must be removed from job site by Contractor. FEES DESCRIPTION ACCOUNT QUANTITY PAID AMOUNT BUILDING PLAN CHECK 455-0000-322-1001 0 $17.50 FENCE 455-0000-322-1000 0 $35.00 PW REVIEW BUILDING MOD OR ROW 001-0000-329-1004 0 $25.00 STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.00 STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00 TOTAL:$81.50 Issued Date:2/25/2020 2 of 2 o,m-r4, City of Atlantic Beach APPLICATION NUMBER t r, Building Department (To be assigned by the Building Department.) 800 Seminole Road FN G� Zv _ LU t r X)`� Atlantic Beach, Florida 32233-5445 l/ 1 Phone(904)247-5826 • Fax(904)247-5845 ;�1 0.71tq'r E-mail: building-dept@coab.us Date routed: 2X) City web-site: http://www.coab.us APPLICATION REVIEW AND TRACKING FORM IDA Property Address: C) I ( j Ro oL L ,A Linn Department review required Ye No p Y .Buildin_� A licant: fanning &Zoning Tree Administrator Project: Lc",' j.( �� Public Works Public Utilities': Public Safety Fire Services Review fee $ Dept Signature Other Agency Review or Permit Required Review or Receipt Date of Permit Verified By Florida Dept.of Environmental Protection Florida Dept.of Transportation St.Johns River Water Management District Army Corps of Engineers Division of Hotels and Restaurants Division of Alcoholic Beverages and Tobacco Other: APPLICATION STATUS Reviewing Department First Review: t Approved. ❑Denied. ❑Not applicable (Circle one.) Comments: BUILDIN PLANNING &ZONING Reviewed by: Dater.)// 2020 TREE ADMIN. Second Review: ['Approved as revised. ❑Denie . ❑Not applicable PUBLIC WORKS Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: I 'Approved as revised. ❑Denied. ['Not applicable Comments: Reviewed by: Date: Revised 05/19/2017 , s'y'''%- Building Permit Application Updated tit= OFFICE COPY **ALL of Atlantic Beach Building Department INFORMATION 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY on IS REQUIRED. Phone: (904) 247-5826 Email: Building-Dept@coab.us Job Address: SlO y/4 /�c I" 1N''S i9/• Permit Number: I I�C'C= ZED 0t.J t l Legal Description V N.t y/ F�ycQ � - RE# 71 5 (4 -0 000 Valuation of Work(Replacement/ Cost)$ Z-/'I5.99 Heated/Cooled SF Non-Heated/Cooled • Class of Work: ❑New ❑Addition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door • Use of existing/proposed structure(s): ❑Commercial ❑Residential • If an existing structure,is a fire sprinkler system installed?: ❑Yes ❑No • Will tree(s)be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) ❑No Describe in detail the type of work to be performed: <t Cry c_#, A✓'o s/,'I S ISO V S e_ F / mac 4 A,1-/ Y Florida Product Approval# for multiple products use product approval form Property Owner Information Name c lgck F- ,✓ Address City 4.Q State i--:C Zip 7 2 Z 3 3 Phone 510 3- ?C, / ," E-Mail .1 O9,n @ VAhc.,.-' C_os+, Owner or Agent(If Agent, Power of Attorney or Agency Letter Required) Contractor Information Name of Company S✓p'j;..r I.'_r Ce Qualifying Agent Address 5/O i2-y,,,.0 /'. /'-S Pe City 2.3 State )44- Zip 32'z 3 Office Phone (a-() S6 3-3 C. Pc' Job Site Contact Number State Certificatio /Registration# _ - E-Mail ,j I(DI,',/ lf131 Y/1-l7 CPc., , c..0,4' Architect Name&Phone# Engineer's Name&Phone# Workers Compensation Insurer OR Exempt o Expiration Date Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all the laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS,TANKS,and AIR CONDITIONERS,etc. NOTICE: In addition to the requirementufthis permit,there may be additional restrictions applicable to this property that may be found in the public records of"this countOnd there may be additional permits required from other governmental entities such as water management districts,state agent,or CO federal agencies. = Q ZO J V Z OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work wiE Udonan 2 fiance wit I Q O E c' applicable laws regulating construction and zoning. O m O O I- WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT}MAMj p Q o RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTI o a TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE U g RECORDIN ' • 6 F COMMENCEMENT. 0 g M w U. > (Sign.ture of.caner or Agent) (Signature of Contractor) L!1 a - LU 5 W o u. i.g-ned and sworn to(or affirRmed/bef re me this 7 day of Signed and sworn to(or affirmed)before me this dWo� N I LL r` v —cam \j �C' Cftby\ QQ �� ( J d .� by LLJ> 5 CC CL-:-_,..- (S�gr?aturNo ry) , �P l!16,15a of Notary) TONI GINDLESPERGER MY COMMISSION#GG 353178 1.74e7g.-'_ IRE$ ctober 6,2023 [ ] Personally Known OR (.• '; CIlid'n'°,' ru ollaarryyPublcUnderw•rrrlers [ ]Produced Identification h /1 // —' " ' ,. .c:. Type of Identification: U LS '`[ ZCo'(5,a•( Z J._Type of Identification: LL Owner Builder Affidavit **HIGHLIG INFORMATIONEIN 'frit". HIGHLIGHTED IN City of Atlantic Beach Building Department GRAY IS REQUIRED. 111 157far 800 Seminole Rd, Atlantic Beach, FL 32233 ``nt''r Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: I. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES, PART 1"CONSTRUCTION CONTRACTING" REQUIRES OWNER/BUILDER TO ACKNOWLEDGE THE LAW: DISCLOSURE STATEMENT FOR SECTION 489.103(7), FLORIDA STATUTES: STATE LAW REQUIRES CONSTRUCTION TO BE DONE BY LICENSED CONTRACTORS. YOU HAVE APPLIED FOR A PERMIT UNDER AN EXEMPTION TO THAT LAW. THE EXEMPTION ALLOWS YOU,AS THE OWNER OF YOUR PROPERTY,TO ACT AS YOUR OWN CONTRACTOR EVEN THOUGH YOU DO NOT HAVE A LICENSE. YOU MUST SUPERVISE THE CONSTRUCTION YOURSELF. YOU MAY BUILD OR IMPROVE A ONE OR TWO FAMILY RESIDENCE OR A FARM OUTBUILDING. YOU MAY ALSO BUILD OR IMPROVE A COMMERCIAL BUILDING AT A COST OF$25,000.00 OR LESS. THE BUILDING MUST BE FOR YOUR USE AND OCCUPANCY. IT MAY NOT BE BUILT FOR SALE OR LEASE. IF YOU SELL OR LEASE A BUILDING YOU HAVE BUILT YOURSELF WITHIN ONE YEAR AFTER THE CONSTRUCTION IS COMPLETE,THE LAW WILL PRESUME THAT YOU BUILT IT FOR SALE OR LEASE,WHICH IS IN VIOLATION OF THIS EXEMPTION. YOU MAY NOT HIRE AN UNLICENSED PERSON AS YOUR CONTRACTOR. YOUR CONSTRUCTION MUST BE DONE ACCORDING TO THE BUILDING CODES AND ZONING REGULATIONS. IT IS YOUR RESPONSIBILITY TO MAKE SURE THAT PEOPLE EMPLOYED BY YOU HAVE LICENSES REQUIRED BY STATE LAW AND BY COUNTY OR MUNICIPAL LICENSING ORDINANCES. II. INJURY LIABILITY;SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE,THE BUILDING DEPARTMENT SUGGESTS WORKER'S COMPENSATION INSURANCE BE PURCHASED. . III. IRS WITHHOLDING;OWNERS HIRING WORKERS BECOME EMPLOYERS AND SHOULD ALSO OBSERVE IRS WITHHOLDING TAX AND/OR FORM 1099 REQUIREMENTS ON THE WORKERS THEY EMPLOY ON THEIR IMPROVEMENT TRADES. IV. PENALTY; UNLICENSED CONTRACTORS CANNOT BE EMPLOYED UNDER ANY CIRCUMSTANCES. OWNERS BEING SUBJECT TO$5,000 PENALTY UNDER FLORIDA STATUTE NO. 455-228(1). AN "OCCUPATIONAL LICENSE" IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALLY SEE THE COUNTY"CERTIFICATE OF COMPETENCY" OR THE FLORIDA"CONTRACTORS CERTIFICATE"TO ASCERTAIN IF A PERSON ISA LICENSED CONTRACTOR. CONTACT THE BUILDING DEPARTMENT(904- 247-5826 OR BUILDING-DEPT@COAB.US) IF IN DOUBT. V. ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN OWNER-BUILDER PERMIT. Job Address: 5/o I2 /,;<-C- /1r--C I',S Or Owner Name: -7/Pc F. b'J Phone Numberl(�yr— 3 '3 / Mailing Address: 6/O A)714(. /0,-(41-,s. £2r City: f2/3 State: ieC Zip: 5 2 2' 3 3 Notarized Signature of Owner _',,.,i __ /,i►� The fFlegoing instr ent was a owle.:-. .- ore m- -'s C>da of 1 , 20 • the State of Florida, County of (WCJ Signature of Notary Pub [ ] Personally Known OR [ ] Produced Identification , "4 TONIGINDLE;PERGER . fik. MY,.0`.1MISSION#GG353178 Type of Identification: j°. ° EXPIRES:October 6,2023 `;.�_+ Bonded Thn;Nc;arJ,Put:ic Underwriters Updated 10/24/18 • • . MAP SHOWING SURVEY OF Lor /9 - /560C K /7 SPE_PCAT OF P,47- of ,42oY46 P,46/vis" CIA 1l T TA/0 A AS RECORDED IN PLAT BOOK 3/ PAGES /o.,'67D('K'/1-5/`‹PIF THE CURRENT PUBLIC RECORDS OF Du va( COUNTY. FLORIDA CERTIFIED TO 8QeA1r 4 . °^d D(y_o,)Es 4• ,E'PEC4, 80G OYtiuOECF�R5r / , Mo.P rC4G o ,Q471r. ".q e6 /'; Zp , /elaY4 4 A15 Q P/ V6 ( 0 "e/A0 5. 07' /( '02 'x. 6b•&5 ' v. r . O tr , ' O 61 : ' Q • COAX'.u)4Le o/ .$ :A - 3'. COV "(' ' itk Q PEA 44.0 i3 4� °0 C) o q 6C4-14 cf 43 /- 57c 'y C AJC'. 13, �i.2 ti &OC' ti I f CL adu-, op • i2.8' N0. .5/0 k 'Sl °, 57b,P.4GE j _ v,_. !Z•9' 44.0 o •s,- a, i" • OG . N __4_, , ki N) 0 01v kJ I 2 .;aP NJ4. 1\ 4.*a431 o. .1 : 'i0' 544'7 FOP r�.P,(•6. urs e. .fk Y1.1: K u f N 07° /0 "02 W. go. 65. to r 5 C o r 6 L o r 7 ig- 1 oLA,y;y, City of Atlantic Beach APPLICATION NUMBER el itilliwBuilding Department (To be assigned by the Building Department.) i 800 Seminole Road /� rr L io Atlantic Beach, Florida 32233-5445 EN G) ZU — 00 1 ( ,v Phone(904)247-5826 • Fax(904)247-5845 �, ,�^l 01119'r E-mail: building-dept@coab.us Date routed: �J City web-site: http://www.coab.us APPLICATION REVIEW AND TRACKING FORM Property Address: () k O C- !-�l_ r �1 LI�`� s Department review required Yes No p Y uildin_gj.)' L �. '� c--6-(- _, tanning &Zoning"''~) Applicant: .0 ( ,0n..) f -- 7— Tree Administrafor___ Project: (.j ( �,.i -)C—e- ~ public Work .r.;:, Public Utilities Public Safety Fire Services Review fee $ Dept Signature Other Agency Review or Permit Required Review or Receipt Date of Permit Verified By Florida Dept.of Environmental Protection Florida Dept.of Transportation St.Johns River Water Management District Army Corps of Engineers Division of Hotels and Restaurants Division of Alcoholic Beverages and Tobacco Other: APPLICATION STATUS Reviewing Department First Review: Approved. Denied. Not applicable (Circle one.) Comments: BUILDING PLANNING &ZONING Reviewed by: Date:1_ G-ZG TREE ADMIN. Second Review: Approved as revised. Denied. I 'Not applicable PUBLIC WORKS Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: Approved as revised. ❑Denied. Not applicable Comments: Reviewed by: Date: Revised 05/19/2017 City of Atlantic Beach ECEIVEAPPLICATION NUMBER Building Department (To be assigned by the Building Department.) 800 Seminole Road FEBC- -- 10 - 00 , :, Atlantic Beach, Florida 32233-5445 10 �N ( Phone(904)247-5826 • Fax(904)247- 5 jay E-mail: building-dept@coab.us Date routed: 1 /7 /7-0 City web-site: http://www.coab.us APPLICATION REVIEW AND TRACKING FORM Property Address: I CD K 011AL pp,411 S Department review required Yes No (BuildincL:..)_ Applicant: U CON)C-_6 (fanning &Zoning Tree Adminis gator Project: Lc7 F-- \-) Pb lic Work L.> Public Utilities; Public Safety Fire Services Review fee $ Dept Signature Review or Receipt Other Agency Review or Permit Required of Permit Verified By Date Florida Dept.of Environmental Protection Florida Dept.of Transportation St.Johns River Water Management District Army Corps of Engineers Division of Hotels and Restaurants Division of Alcoholic Beverages and Tobacco Other: APPLICATION STATUS Reviewing Department First Review: /Approved. ['Denied. Not applicable (Circle one.) Comments: BUILDING PLANNING &ZONING Reviewed by;11 Date: oG-V1_10 TREE ADMIN. Second Review: ['Approved as revised. ❑Denied. ['Not applicable PUBLIC WORKS Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: Approved as revised. ❑Denied. Not applicable Comments: Reviewed by: Date: Revised 05/19/2017 ss , RIGHT-OF-WAY/ EASEMENT PERMIT APPLICATION **ALL INFORMATION `Y frl,* City of Atlantic Beach HIGHLIGHTED IN GRAY IS A ' 800 Seminole Road,Atlantic Beach, FL 32233 REQUIRED. vier PERMITTEE RESPONSIBLE FOR NOTIFYING 811 AND OBTAINING UTILITY LOCATES�J Job Address 5j0 12 7 -C f P'7I S a- Permit Number FiC 2O-0O 1( Contractor Information Company S'ci f�Ql','u,r' 1 icy Ccs Qualifying Agent Address S/ 0 /2- 7N.0 /12/w•S 19/ City A. 3 State Zip ;Z? 3 3 Phone Ce70,95G 3-3c,/gEmail s$ j :O5 ► n € Ul2Grc.v. Gam State Certification/Registration# •/ C Architect Phone Email Engineer Phone Email Workers Compensation Insurer OR Exempt ❑ Expiration Date • Permittee declares that prior to filing this application they have ascertained the location of all existing utilities,both aerial and underground and the accurate locations are shown on the sketches. • Whenever necessary for the construction, repair,improvement, maintenance,safe and efficient operation,alteration or relocation of all,or any portion of said street or easement as determined by the Public Works Director,any or all said poles, wires, pipes,cables or other facilities and appurtenances authorized hereunder,shall be immediately removed from said street or easement or reset or relocated hereon as required by the Public Works Director and at the expense of the Permittee unless reimbursement is authorized. • All work shall meet City of Atlantic Beach or Florida Department of Transportation Standards and be performed under the supervision of (Project Superintendent) with (Company Name) Phone • All materials and equipment shall be subject to inspection by the Public Works Director. • All city property shall be restored to its original condition as far as practical,in keeping with City specifications and the manner satisfactory to the City. • A sketch of plans covering details of this installation,as well as a copy of a recent survey shall be made a part of this permit. Calculations showing any increase in impervious area on owner's lot or in the City right-of-way are to be included with this application. • The permittee shall commence actual construction in good faith within days. If the beginning date is more than 60 days from date of permit approval then permittee must review the permit with the Public Works Director to make sure no changes have occurred in the area that would affect the permitted construction. • It is understood and agreed that the rights and privileges herein set out are granted only to the extent of the City's right, title and interest in the land to be entered upon and used by the holder,and the holder will,at all times,assume all risk of and indemnify,defend and save harmless the City of Atlantic Beach from and against any and all loss,damage and cost of expenses arising in any manner of the exercise or attempted exercises by the holder of the aforesaid rights and privileges. • The Public Works Director .- be notified 24 hours prior to starting work and again immediately upon completion. -41P. PPPDate z'7-20 Per - ee(si:• -•-m pre - e of otary Public) STAT IF FLORIDA,CSUN OF DUVAL ` 1 1 ` 0/l The foregoing instrument was acknowledged this / day of I t✓ 1-3 ,20 -7 , L C, "" by 1 . - c : me and ( (printed na ule of Permittee) _.,47 u:,• TONI GINDLE • ' - MY COMMISSION#GG 353178 ackn ledged tI(}at he/ a signed the instrument voluntarily for the purpose ex. 21s��_,i i :0ctober6,2023 •:lEOF f��,P: Bonded TIYU NO1afY Public BfW111bri I ir \ L l T [ ] Personally Known Signature of Notary Public,State of Flor is [ ] Produced Identification (Type) (� (_-- H:\Applications&Forms\Word&Excel Document Originals\201801001 Right-of-Way Easement Permit Application.docx Revision Date:10/1/18 I REVOCABLE ENCROACHMENT AGREEMENT � **ALL INFORMATION .. \ City of Atlantic Beach;f� HIGHLIGHTED IN GRAY 5:11:-7,,i: 800 Seminole Road,Atlantic Beach, FL 32233 IS REQUIRED. REVOCABLE ENCROACHMENT AGREEMENT by the City of Atlantic Beach, Florida, a municipal corporation organized and existing under the laws of the State of Florida, hereinafter referred to as "CITY" and U S C� of Atlantic Beach, Florida, hereinafter referred to as"USER". WITNESSETH: That the CITY does hereby grant the USER permission on a revocable basis as described herein the right to enter upon the property for the purpose as described in the City of Atlantic Beach., � !' This work is generally described as ed1c 2 .7',7 s.k.(x • Any facility maintained, repaired, erected, and/or installed in the exercise of the privilege granted remains subject to relocation or removal on thirty(30)days' notice by CITY to USER,said notice to USER shall be given by certified mail,return receipt requested,to the following address 570 Ro 'wC /#1,5L./1.4.s /9,e 4/3 X( 3 2 23 3 • In the event it is necessary for the CITY or the City's approved representative or other franchised utility to enter upon the above described easement or property of the CITY, the USER shall replace at the USER's sole expense, any and all material necessarily displaced during the action of maintaining, repairing, operating, replacing or adding to of the utilities and facilities of the CITY or franchise utility provider. • The facilities allowed by the permit shall meet the current requirements of the City Code, Building Codes, Land Development Code and all other land use and code requirements of the CITY, including City Code Section 19-7(h) which states "Driveways that cross sidewalks: City sidewalks may not be replaced with other materials, but must be replaced with smooth concrete left natural in color so that it matches the existing and adjoining sidewalks." • The USER, prior to making any changes from the approved plans and/or method, must obtain written approval from the City of Atlantic Beach Public Works Department, for said change within 30 days after the day of completion. • This permit shall inure to the benefit of, and be binding upon, the USER and their respective successors and assigns. • USER shall meet the terms and conditions of this permit and to all of the applicable State and CITY laws and/or specifications, to include utilities locate requirements and use limitations/requirements of easements, public right-of-ways and other public land. USER further agrees that the CITY and its officers and employees shall be saved harmless by the USER from any of the work herein under the terms of this permit and that all of said liabilities are hereby assum-d by the USER. .4111119 001 Date Z-7- 20 Prop• • 2 r/Agent signed i► . -sence of Notary Public) STATy F FLORIDA, COUNTY OF DUVAL (---7 L. The foregoing instrument was acknowledged this 7 day of ' -e-- i_ _.J , 20 b 7, � • L _ by QL, ' f r\ , who personally appeared before me and i (printed name of Signer) acknowledged th t� he/sh signed e instrument voluntarily for the purpose expressed in it. �/ jC _ Department Approval: Signature of Notary Public,State of Fiala "" TONI GINDLESPERGER '-: ., MY COMMISSION i�GG 353178 I �,67/, 114.4''2 [ ] Personally Known :•. :*' i� `;; ,��`�•iT EXPIRES:October 6,2023 1 ) [ ] Produced Identification(Type) . C _ `•fq•F, ;°"' Bondennpkwyp, a„ 1 Williams, Public Works Director H:\Applications&Forms\Word&Excel Document Originals\20180831 Revocable Encroachment Agreement.docx Revision Date:8/31/18 ri.��'i ; City of Atlantic Beach APPLICATION NUMBER t Building Department (To be assigned by the Building Department.) 800 Seminole Road !�--�� r� Atlantic Beach, Florida 32233-5445 1— N ��- Z-0 r VU i Phone(904)247-5826 • Fax(904)247-5845 .vri r E-mail: building-dept@coab.us Date routed: City web-site: http://www.coab.us APPLICATION REVIEW AND TRACKING FORM Property Address: CD I ( ) RO( oL r-1)Lifl S Department review required Yes No Buildin Applicant: L g(Planning &Zoninh i _Tree Adminstr iaTor- Project: ( -•' ce Public Worrka Public Utilities ') Public Safety Fire Services Review fee $ Dept Signature Other Agency Review or Permit Required Review or Receipt Date of Permit Verified By Florida Dept.of Environmental Protection Florida Dept.of Transportation St.Johns River Water Management District Army Corps of Engineers Division of Hotels and Restaurants Division of Alcoholic Beverages and Tobacco Other: APPLICATION STATUS Reviewing Department First Review: Approved. Denied. of applicable (Circle one.) Comments: BUILDING PLANNING &ZONING // Reviewed by: �/'" Date: 2- i I - 70 TREE ADMIN. Second Review: Approved as revised. Denied. Not applicable PUBLIC WORKS Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: Approved as revised. Denied. Not applicable Comments: Reviewed by: Date: Revised 05/19/2017