1766 BEACH AVE - PAVER PATIO Building Permit Application
Updated 10/9/18
City of Atlantic Beach Building Department **ALL INFORMATION
, 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
•
Phone: (904) 247-5826 Email: Building-Dept@coab.us IS REQUIRED.
Job Address: I7('1#n13PO-Ch Permit Number:
Legal Description �.JCn [ 5��(� /Q RE#
Valuation of Work(Replacement Cost)$ (({ ,C__. 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(sl 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:
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Florida Product Approval# for multiple products use product approval form '
Property Owner Information
Name K• m/7-erIk rim(ptt Address I7( i/ geQ &/' 14-(1-€-
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City State Zip Phone gat/.f/Si-"PO
E-Mail rn taiL 1 ICS vYj�0ma-J .
Owner or Agent(I gent, Power of Atto ey or Agency Letter Required)
Contractor Information
Name of Company
Qualifying Agent
Address City State Zip
Office Phone Job Site Contact Number
State Certification/Registration# E-Mail
Architect Name& Phone#
Engineer's Name & Phone#
Workers Compensation Insurer OR Exempt D 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 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.
OWNER'S AFFIDAVIT:I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
REC?RING YOUR NOTICE OF COMMENCEMENT.
(Sig re Owner or Agent) (Signature of Contractor)
Signed and sworn to(or affirm-d) befor kolt+#Hill ,C day of Signed and sworn to(or affirmed) before me this day of
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by
as /fit ��SaiON FXaj9•• �i
otarp3 * _ (Signature of Notary)
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jarsonally Known OR a.' ` e-;--a , Known OR
[ )Produced Identification �!:g ••. ..•• pk �`` [ j Produced Identification
Type of Identification: //ij,, �e LACI �`.$ Type of Identification:
-'t-w REVOCABLE ENCROACHMENT AGREEMENT **ALL INFORMATION
1111% City of Atlantic BeachHIGHLIGHTED IN GRAY
MY it, 800 Seminole Road,Atlantic Beach, FL 32233 IS REQUIRED.
REVOCABLE ENCROACHMENT AGREEMENT by the City of Atlantic Beach,Florda, a municipal corporation organized and
existing under the laws of the State of Florida, hereinafter referred to as"CITY" and
1 rrl91ell 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 / `
j "7
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 o USER shall be given by certified mail,return
receipt requested,to the following address ) 1£P 4 /� =at ',
• 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 assumed by the USER.
COi �� Date 6.7)0
Property Owner/Agent j: ed in presence of Notary Public)
STATE OF FLORIDA, COUNTY OF DUVAL
The foregoing instrument was acknowledged this a 6 day of vnF'_ , 20 .d 0 ,
by K I t/Y) 1) 7I/ 'U /Ylc cf I- k( , who personally appeared before me and
(printed name of Signer)
acknowledged that he/she signed the instrument volunt\010AIMP94.irpose expressed in it.
/�� •'�SS10N EXP,y' � /
de" ��•••i', ,,', 20�`'r '•4( Department Approval:
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Sig ur: lir otary Public,State of Florida _ p2
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[ Persona y Known T--:',3‘`
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( ] Produced Identification(Type; '� ;— :?`�.�� Scott Williams, Public Works Director
H:\Applications&Forms\Word Documen-s\20180831 Revocable Encroachment Agreement.docx Revision Date:8/31/18
HAP SHOWING BOUNDARY SURVEY OF
LOT 7, (EXCEPT THE WESTERLY 83.34 FEET) OCEAN GROVE UNIT NO 2, AS RECORDED IN PLAT
BOOK 20 PAGE 20 OF THE CURRENT PUBLIC RECORDS OF DUVAL COUNTY, FLORIDA AND THE
FOLLOWING AS DESCRIBED IN DEED RECORDED IN DEED BOOK 1361, PAGE 393 OF SAID PUBIC
RECORDS COMMENCE AT THE NORTHWESTERLY CORNER OF LOT 33 NORTH ATLANTIC BEACH UNIT 11,
R-CB-S CORPORATION, ACCORDING TO PLAT RECORDED IN PLAT BOOK 15 PAGE 10 OF THE PUBLIC
RECORDS OF SAID COUNTY, THENCE WESTERLY ALONG AN EXTENSION OF THE NORTHERLY LINE OF
SAID LOT 33, A DISTANCE OF 25 FEET MORE OR LESS TO THE WEST SIDE OF GARAGE APPROACH
ROADWAY (SAID ROADWAY BEING INDICATED ON SAID MENTIONED PLAT) FOR A POINT OF BEGINNING
OF THE LAND HEREBY CONVEYED; THENCE SOUTHERLY ALONG THE WEST SIDE OF GARAGE APPROACH
ROADWAY, A DISTANCE OF 50.06 FEET, MORE OR LESS, TO A POINT LYING IN AN EXTENSION OF THE
SOUTHERLY LINE OF SAID LOT 33, IF EXTENEED IN A WESTERLY DIRECTION; THENCE WESTERLY ALONG
A LINE COINCIDING WITH THE SOUTHERLY LINE OF SAID LOT 33, IF EXTENDED IN A WESTERLY
DIRECTION (THAT IS TO SAY PARALLEL WITH THE SOUTHERLY LINE OF EIGHTEENTH STREET) A
DISTANCE OF 50 FEET TO A POINT; THENCE NORTHERLY ALONG A LINE PARALLEL TO THE WESTERLY
SIDE OF SAID GARAGE APPROACH ROADWAY, A DISTANCE OF 50.06 FEET, MORE OR LESS TO A
POINT LYING IN AN EXTENSION Cr THE NORTHERLY LINE OF SAID LOT 33 IF EXTENDED IN A
WESTERLY OIREC770N; THENCE EASTERLY ALONG A UNE COINCIDING W1 TH THE NORTHERLY LINE OF
SAID LOT 33, IF EXTENDED IN A WESTERLY DIRECT70N, A DISTANCE OF 50 00 FEET TO THE POINT
OF BEGINNING IN THE WESTERLY SIDE OF GARAGE APPROACH ROADWAY.
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ALL CORNERS FOUND 1/2" IPS NO 10
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CERTIFIED FOR: KIMBERLY MA GLEY
THE PROPERTY SHOWN HEREON APPEARS TO LIE WITHIN FLOOD HAZARD ZONE X AS SCALED FROM FLOOD
INSURANCE RATE MAP 407 FOR DUVAL COUNTY, FLORIDA, DATED 11-2-18 . AND
IS SffOMN AS A COURTESY ONLY AND DOES NOT CONSTITUTE A CFRnFCAnnN nF SAu
Owner Builder Affidavit **ALLILIGHTED IN
ION
,�}*��': � HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
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800 Seminole Rd, Atlantic Beach, FL 32233
. Phone: (904) 247-5826 Email: _ widing-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 IS A 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: / 7(040 /3PQ. -I-, AO-X.-- ��yy��ll// (� p�
Owner Name: .0 r7-7 h.er 1 (nag LEL/ Phone Number: gaiN n`dn
Mailing Address: ivp 49 /sew-) Atke City: + State: Zip: 3aa 3 3
Notarized Signature of Owner
The foregoing instrument was acknowledged before mYthis 6,1 6 day of n , 20v'CO3 in the State of Florida, County
of
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��PGEN . *moi
O ap�RES b. Sig tune of Notary Public
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z ; � , „; Personally Known OR [ ] Produced Identification
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,/,,'////0 1111111H0`\\\\\\ _=:'ed 10/24/18