353 7 ST FNCE21-0008 Building Permit Application Updated 10/9/18
rf
w City of Atlantic Beach Building Department **ALL INFORMATION
V 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
• P.
IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us /`�
Job Address: /s�j 1." S �t� 4-441- Permit Number: � G � l E ft v 0 O8
Legal Description " <) 'l b 2S_ 1.9
c t •11 1 , , l 'l S 724-2.4 RE# /699'3 1 coo f r
Valuation of Work(Replacement Cost)$ Cn t5-0-0 Heated/Cooled SF Non- Heated/Cooled
• Class of Work: ENew ❑Addition ❑Alteration XRepair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial OResidential
• 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) VNo
Describe in detail the type of work to be performed: 6 4+ tot-
Florida Product Approval# _ for multiple products use product approval form
Property Owner Informationn ^
Name �LA/�. ��f1.0 5 ��T`-(-Z Address >.; 7
City State L. Zip )'1-2 7j Phone ,,'( zs 2- of `(
E-Mail )C L('h vk l.�p{'.�1�i� • (tee AA
Owner or Agent(If Agent, Power of Attorneyr Ag n y Letter Requir d)
Contractor Information J� ma_ -{'l(� Cly
Name of Company v CP Qualifying Agent bAVtok b( 1/4/ '44-3-11
Address SIS 1 S v.i c/ZA n l2-,( I tt City )A..$. State r't- Zip 12-Z 7
Office Phone Job Site Contact Number
✓
State Certification/Registration# N' t.. E-Mail ��OG/vaACc-A,Le.- c.. At
Architect Name&Phone# Z O '-t 11/
Engineer's Name&Phone#
Workers Compensation Insurer (11,112--K 1 OR Exempt❑ Expiration Date /4171'`
Application is hereby made to obtain a permit to do the work a installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all w will be performed to meet the staff'dardsofaff t,he-laws.regu[atin
construction in this jurisdiction. I understand that a sepa to permit must be secured for ELECTRICAL WO'RIc PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS,TANKS,and AIR CONDITIONERS,etc. NOTICE: In addition to the requirements Of this
permit,there may be additional restrictions applicable to this property that may be found in the public records of this county,and
there may be additional permits required from other governmental entities such as water management di$tl-'l4ts,state ncies,or
federal agencies. JAIV
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. 4
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 BEFefiE
REC&RDI G YOUR NOTICE OF COMMENCEMENT.
(Signature of Owner or Agent) (Signat e of Contractor)
001
Signed and sworn to(or affirmed) before me this l"' day of Signed and sworn to(o affirmed)before me this day of
U44-N�,�/ , y°Y0 , by Z. 11 CGulc7S µ6k1{i!1a , by
(Signature of Notary)
JENNIFER JOHNSTON
*. • :.
WY COMMISSION#NH 057579
[ ]PersonallyKnown OR I;y7,-''�` EXPIRES:October 27, ] Personally Known OR
'•'►oi n�?p:' 2024 y
[ oduced Identification T ruNotaryPrLAcurxierwr ] Produced Identification
Type of Identification: L- Ai 41 Li Type of Identification:
-r REVOCABLE ENCROACHMENT AGREEMENT
/_ , ``) **ALL INFORMATION
ff�s stn City of Atlantic Beach
4 l'� 800 Seminole Road,Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
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
1v1.A ck rc,-13 S ?"44."4- 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 Crvl y"e_r&lv
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 3S- 1, 7 S i..<_ . 7f` A-6 (=L 322-.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 assumed by the USER.
Datel2 l 'it ( 1,4
Prop In Owner/Agent (signed in presence of Notary Public)
STATE OF FLORIDA, COUNTY OF DUVAL
The foregoing instrument was acknowledged this day of 6 t?c_2rn at/ , 20 a C�, ,
by ika_a e_a_i .QL , who personally appeared before me and
(printed name of Signer)
acknowledged that he/she signed the instrument vel .r,+arid Jnr the our ose expressed in it.
I0675or:v: JENNIFER JOHNSTON
:1„s MY COMMISSION
79
A i i�•' po' EXPIRES;Osfobe 272024 Department Approval:
Signa re of Notary Public,State of Florida I ... Bonded1bnNctaryPubicU i s
[ j Personally Known
(,]4oduced Identification (Type) F� (�Lf.k\a- S Scott Williams, Public Works Director
H:\Applications&Forms\Word&Excel Document Originals\20180831 Revocable Encroachment Agreement.docx Revision Date:8/31/18
rs i a,�ri
Owner Builder Affidavit **ALL INFORMATION
HIGHLIGHTED IN
'J `' City of Atlantic Beach Building Department GRAY IS REQUIRED.
'v 800 Seminole Rd, Atlantic Beach, FL 32233 JJ((¢(�
-turns).- Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:17N CGZ 1-U0V(�
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-DEPTPCOAB.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: e3c- .41AS A'P 1" 1, 3 Lz 3 3
Owner Name: 3.Jktt V&v(M MAN'+444 Phone Number: 1O1 L Z c01'1,1
Mailing Address: 3 S3 1 nA Si- City: r '(77 State: C- Zip: 31 Z 3 3
Notarized Signature of Owner
Thechseregoing instrment was ackno 4'ged before me this 7 day ofs--- t...-) , 207_1, in the State of Florida, County
of 4 __kW(
Signature of Notary Public - l! _ C�
[ ] Personally Known OR [ ] Produced Identification
Type of Identification: �.
�' vOLESPERGER Up, ted 10/24/18
� M t tY
itt� i
lS.SION#GG 353178
11; i '; r•RES:October 6,2023
i —,ruNotaryPublicUrue;rr 's,3
12/16/2020 Protected By Symantec
I • MAP OF SURVEY
LOTS 22 AND 24, BLOCK 9, PLAT No. 1, SUBDIVISION "A", ATLANTIC HACH, AS RECORDED IN PLAT
BOOK 5. PAGE 69 OF THE CURRENT PUBLIC RECORDS OF DUVAL COUNTY, FLORIDA.
,
LOT 25 I LOT 23 I LOT 21 LOT 19
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7th STREET
40. RIGHT OF WAY PAVED
NOTES:
THIS IS A BOUNDARY SURVEY WITH TREE LOCATIONS
NO BUILDING RESTRICTION LINES AS PER PLAT.
ANGLES AS PER FIELD SURVEY:
A 89'58'03"
O 5.012'07"
C 8943'07"
:
, D 900643"
,
• E 8956'02" 0
F 89'52'40"
G 90'13'53"
H 89'55'25"
NORTH ARROW PROTRACTED FROM PLAT.
: THE PROPERTY SHOWN HEREON APPEARS TO LIE IN FLOOD ZONE "X" THIS SURVEY WAS MADE FOR THE BENEFIT OF
' (AREA OUTSIDE 500 YEAR FLOOD PLAIN) AS WELL AS CAN BE PHILLIPS/..WILDERS.
DE-ERMINED FROM THE "FLOOD INSURANCE RATE MAD"
, COMM„NITY-PANEL NUMBER 120075 0001 D REVISED APRIL 17, 1989 1 h I t
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R TI-,i ('IT,' CZ'
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https://docisolation.prod.fire.glass/?guid=628f1472-d363-4d3d-3a85-4afa64d2f755 1/2
NOTICE OF COMMENCEMENT nnl
State of Tax Folio No. � qq 3 / O C� 1
County of 16U V l.—
To Whom It May Concern:
The undersigned hereby informs you that improvements will be made to certain real property, and in accordance with Section 713
of the Florida Statutes,the following information is stated in this NOTICE OF COMMENCEMENT.
Legal Description of property being improved: S - 69 1 (, - 2.J` ~'2 E ''( '
f,e+ s ii K ) d b1-g- 9
Address of property being improved: 3 s 1 1 S!-(,12`
General description of improvements: •t-.L( i v (r i s cc (-c 14s/Lu.,'f_ � C
Owner: 1 WV S / c,/L~1 -2 Address: 5-3 V.' St
Owner's interest in site of the improvement:
Fee Simple Titleholder(if other than owner):
Name: ,`1�
Contractor: b V v t.Jc.. FG✓i co, ,� nn i
Address: 71 5 ,.,1 -j S �v1K lJc JLC L �L2S7
Telephone No.: ?Az, d "(1 7 Fax No: 26 0 H Z S
Surety(if any)
Address: Amount of Bond$ •
Telephone No: Fax No:
Name and address of any person making a loan for the construction of the improvements
Name:
Address:
Phone No: Fax No:
Name of person within the State of Florida,other than himself,designated by owner upon whom notices or other documents may
be served: Name:
Address:
Telephone No: Fax No:
In addition to himself, owner designates the following person to receive a copy of the Lienor's Notice as provided in Section
713.06(2)(b), Florida Statues. (Fill in at Owner's option)
Name:
Address:
Telephone No: Fax No:
Expiration date of Notice of Commencement(the expiration date is one (1)year from the date of recording unless a different date is
specified):
THIS SPACE FOR RECORDER'S USE ONLY OWNER
Signed: Date: t1//1;1111 -01-‘2
Before mehit s 'a-j- day of 0.tapli0 _faC&Oin the County of Duval,State
Doc#2021005190,OR BK 19528 Page 77, Of Florida,has personally appeared 'Zf\AALcn1 h Lel(DS �'t�((1i A l�
Number Pages:1 Notary Public at Large,St Florida,County of e -
Recorded 01/07/2021 02:39 PM, My commission expires: JENNIFER JOHNSTON
JODY PHILLIPS CLERK CIRCUIT COURT DUVAL Personally Known: = ` ,. ,
'
RECORDING $10.00 COUNTY
Produced Identification: -i, (�1' `S li P i'x.�_'. �u•r ••....: 1� spa
�2d
"" P7,6?,' Banded Thu Notary P' Ic Unde Undermines '