51 FORRESTAL CIR RFNC21-0007 Building Permit Application Updated 10/9/18
Air I; City of Atlantic Beach Building Department **ALL INFORMATION
1800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
ort'ar IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
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Job Address: 5l Fo rr�r���,1 C;c t I(Si t�ala„1 ,'3c,ch Permit Number: R-�N C. - 0007
Legal Description gO — 2S -)36 AILAstic J14,44 04)I t I RE# /7/'Z 38-- 0000
Loi luir.
Valuation of Work(Replacement Cost)$ l 2-100 0 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: UNew ❑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 iNo
• Will tree(s) be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) '6r No
Describe in detail the type of work to be performed: f eo c( ! 4-
6
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Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name MtCJhowA'90144-.4 2N0at H4•CtCy ' Address S 1 FoYYCS t'aA .G1 mit S
City Akic:LYtk iCr b Cihs State FI. Zip .. z.23 Phone 40U `'fyS 7`' 85
E-Mail YY‘wiewozA,b•1•u4A0e. owhaok.. coy”
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information ���,�[�{ P,
Name of Company V '�'''f#P6S la)j( It- Qualifying Agent 4777.5 �"� 0
Address Z� 1A" Lfr4 City eAtQ-t) State 414 Zip 3c $ZS
Office Phone em— 94— 2-9,15 Job Site Contact Number log- 349- kc; or
State Certification/Registration# E-Mail Pt k .$ B`{GA-roc- ‘A".A-tt. C00-,
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer riei245t4i2E 14.47,4 A"( OR Exempt❑ Expiration Date 4- /1.1—
Application
(3 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 O N ATTO EY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT. >
(Signaturof Owner or Agent) (Signature of ontractor)
Sed and sworn to(or affirmed)before me this /yday of 'gned and sworn--�� to(or affir�% )b fore m this( 3 days
�At�Jcafij 2,2i , by �Vt..4c`.�,�7� , C) � ,by 7
(Si�6�F!'I(�RflNotary) !I, l,.A!Rr7
Commission#GG 328915 TONT GINDLESV ER
Expires April 29,2023
[ ]Personally Known OR • ' +'« "` Bonded Thar Tray Fain Insurance 800-385-7019 [ ]Personally Known OR fN i'-uT ;.-.= MY COMMISSION#GG 353178
[ ]Produced Identificatio• ° EXPIRES:October 6,2023
[U-Produced Identificati 'rF'o'r'F° Bonded Thru Notary Public Underwriters
Type of Identification: Flu;Ac+,_ Type of Identification: "''
.-''----',,,:-ii,, Fence Addendum Updated 1/7/2021
_)
;:-: " ?! City of Atlantic Beach Building Department
800 Seminole Road, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Property Type:
(Residential
❑ Commercial
Lot Type/ Features:
3 One Street frontage (interior lot)
❑ More than one street frontage (corner lot,through lot,etc.)
❑ Swimming Pool
Fence Material:
❑ Wood
❑ Chain Link
XVinyl
❑ Block/Stone (Plan details required for footings and/or retaining walls)
❑ Other
Fence Height:
❑ Four Foot(4ft)
''Six Foot (6ft)
❑ Other
Fence Location:
Please submit an accurate boundary survey required showing all existing improvements (including building footprint,
driveway, swimming pool, etc.) and location of fence/wall and any gates. Plan details required for block wall footings and/or
retaining walls and any portion or fencing above 6ft in height.
Will the fence be built in an easement?
0 Yes (must submit separate Revocable Encroachment Agreement)
❑ No
Will tree(s) be removed in association with proposed project?
❑ Yes(must submit separate Tree Removal Permit)
iNo
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
RECORDING YOUR NOTICE OF COMMENCEMENT.
„f REVOCABLE ENCROACHMENT AGREEMENT
�� ''` 4 **ALL INFORMATION
/,`� VCity of Atlantic Beach HIGHLIGHTED IN GRAY
”! 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 tlaws of the�tate of Florida, hereinafter referred to as"CITY"and
rL7i !c4-4,1205_ QCs ay C.' Y f 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.
r
This work is generally described as I4,:t —1A''t- & d'i\/z Fa'/C1: PAVANOA P,QOP6i1-"/r�
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 5 t CIN-12.6- --0.-c. Q" tse_L it-A_ 6e4-(, '?,,Z j .
• 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-was and other public land. USER further agrees that the CITY and its officers and employees shall be
saved h ml ss by the SER from any of the ork herein under the terms of this permit and that all of said
liabili es ar ereby Is umed by h SER.
' S �Ati 2lbzi
Date
Property wner/Agent(signed in presence of Notary Public)
STATE OF FLORIDA, COUNTY OF DUVAL ,
The f• -;oing instrument was acknowledged this/ 5 day of n , 20-2
by U r--q--1_ 0-1/\�
r--q--1_ S R l71Z- who personally appeared before me and
inted name of Signerf
ackno edged t .t h•/s•a signed the instrument voluntarily for the purpose expressed in it.
• f_
Department Approval:
Signature of Notary Public,Stat• loridaTONI GINDLESPERGER
-,,,;};':(1;:' ,„
[ ] Personally Known COMMISSION#GG 353178
[ ] Produced Identification (Type) (4:1:f..;:,b4?:,L;')
EXPIRES:October6,2023tt edThruNotaryPublicUr..dervrriteZc Williams, Public Works Director
H:\Applications&Forms\Word&Excel Document Originals\20180831 Revocable Encroachment Agreement.docx Revision Date:8/31/18
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