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BACKYARD HEN PERMIT APPLICATION
City of Atlantic Beach
Community Development Department
\ / 800 Seminole Road Atlantic Beach, Florida 32233-5445
�;�1///fir Phone: (904) 247-5826 Fax: (904) 247-5845 Email: Building-Dept@coab.us
SECTION 1: PROPERTY INFORMATION
Property Address: S 7 Li ?la z,g 4'+,3 in fL .3 ez, CL 4::::1...' RE#
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Property Owner Information
Name: A vvi A ea ( vim.e_t-- Phone: coot) S Ly -Z,7C>(Q
Email: 0"k- O rc l.. v'1 cx_i i . C,C.,>"'' Fax: ( ) -
Address: 37 N V Z,:) City: ge L.t. State: PL Zip: 32.23 3
Tenant Information (if applicable)
Name: Phone: ( ) -
Email: Fax: ( ) -
SECTION 2: ITEMS REQUIRED FOR APPROVAL
[j Backyard Poultry Seminar Certificate From the Duval County Agricultural Extension Office.
❑ Passed Inspection of Property Including coop/pen size,construction and location as well as screening.
❑ Approval Letter from HOA(if applicable)
Q• Payment of$50.00 To be paid upon satisfaction of the above requirements.
2- Number Hens to be Kept on Property (limit of 5)
SECTION 3: SIGNATURES
I certify that the information contained herein is true and 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 inspecting
for compliance and agree to remove all hens and associated structures upon the termination or expiration of
a temporary permit and/or this ordinance.
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Signatur f Property Owner Print Name Date
State of F(0,trAok County of F(A Va
Signed and sworn to before me this ,Iv-clday of c_IGt ki , 20 Zd,by Amy
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Signature of Notary Public %`�/4" •t i,Y?u "; MADISON G.HARVEY
,•. : MY COMMISSION#HH 006249
P1 EXPIRES:June 3,2024
1/lad ;sores G -gweye Print Name of Notary Public
❑ ersonally Known
Produced Identification,Type of Identification: nC'yOck Z D.
Updated: 1.17
CERTIFICATE OF COMPLETION
Avery
has completed the UF/IFAS Extension course
Backyard PoultryBasics
for the program
UF/IFAS Extension Baker County
on this date
May 13, 2020
IFAS Extension s`s'S ' >.
UNIVERSITY of FLORIDA '� ,ai
Nick T. Place, Ph.D., Dean and Director ,.,
Florida Cooperative Extension Service ,