1909 MEALY ST DWAY21-0022 'D(-)-YR--/ Z (- W22_
Building Permit Application Updated 10/9/18
r City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
``n yr IS REQUIRED.
Phone: (904)1247-5826 Email: Building-Dept@coab.us z.3 54
Job Address: lu 0 q M4,0 ly s1. - lacriefjeack ri._ Permit Number: i'7 2354 --DOOCD
Legal Description ,� gueie S / RE#
Valuation of Work(Replacement Cost)$ a 1 bet, ec 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:
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Florida Product Approval# for multiple products use product approval form
Propert Owner Information I
Name ,(1'n IC'� E - C-7 1,- o r Address 19( 3Q MeC1 ly d-tree t
City ►\+I State VL Zip 32233 Phone 01)4-504-19:3 45
E-Mail nye A1�i f }�N�Q! ,, ce,/41
Owner or Agent(If Agerrt, Po er o A orney 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 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 pe armed to meet the standards of all the laws regulating
construction in this jurisdiction. I understand that a separate permit st be secured for ELECTRICAL WORK, PLUMBING,SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS,TANKS,and AIR DITIONERS,etc. NOTICE: In addition to the requirements of this
permit,there may be additional restrictions applicable to th' property that may be found in the public records of this county, and
there may be additional permits required from other go rnmental 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
RECORDING OUR NOTICE OF COMMENCEMENT.
/ ------
(Signature of 0 ner or Agent) (Signature of Contractdr)
' ed artd rorn to(or affif.)befo - e i ay fc Signed and sworn to(or affirmed)beOre me this AIIIII day of
� b' Q CD �� �(JP� by
(Si_. f,••,.----.–.__.:. -_— signature of Notary)
•
i!:ii:'F•. TNIN'LESPERGER
? c
�
* =_ MY CO' • SION#GG 353178
aw
[ ]Personally Known OR '•.' :ilk....;;'S EXPIRES:October 6, 0Rers. ally Known OR
odF°; Bonded Thru Notary Public Un:e o' i�'ed Identification
[ ]Produced Identificatio a '
Type of Identification: r Type of Identification: _
rt'' �%li`!r
Owner Builder Affidavit **ALL INFORMATION
�: HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233
-on a 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 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 THE1ISSUANCE OF AN OWNER-BUILDER PERMIT.
Job Address: ( 9 Mealy ,S"fire�, INVIA►TClcT„QGPle)� VD 1,7,4322 n
Owner Name: +}Qr0(01 £• ell Q Phone Number: Qh- T, 4-- 054/55
Mailing Address: icitg kkect ly trQ t City: Atka C Beach State: -FL Zip: 3 22n
Notarized Signature of Owner FS-a0214 f 0- -
The ing instru ent was acknowledged before me thiZ&lay of t ,A , in the State of Florida, County
of
411
Signature of Notary Public
I ] Personally Known OR [ ] Produced Identification
Type of Identification: L
v•. TONI GINDLESPERGER Updated 10/24/18
:*: - MY COMMISSION#GG 353178
EXPIRES:October 6,2023
�F F , Bonded Thru Notary Public Underwriters
4.+►.�.`-,r RIGHT-OF-WAY/ EASEMENT PERMIT APPLICATION **ALL INFORMATION
4 `' • ` y City of Atlantic Beach HIGHLIGHTED IN GRAY IS
R u�:, 800 Seminole Road,Atlantic Beach, FL 32233 REQUIRED.
44,44
PERMITTEE RESPONSIBLE FOR NOTIFYING 811 AND OBTAINING UTILITY LOCATES
32233
Job Address tcCPq )1/44QQ y r et-,M4Y(i r c tdh,f_., Permit Number
Contractor Information
Company Qualifying Agent
Address City State Zip
Phone Email
State Certification/Registration#
Architect Phone Email
Engineer Phone Email
Workers Compensation Insurer OR Exempt o 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 PublicicWorks Director shall be notified 24 hours prior to starting work and again immediately upon completion.
4eutota C .I.&f a Date gal c , -/
Permittee(signed in presence of Notary Public)
STATE OF FLORIDA,COUNTY OF DUVAL '
The foregoing instrument was acknowledged this 2.6:2 day of f ts-( ,20 ...,../,
by I (&( &I, who personally appeared before me and
(printed me•f Permittee)
acknowl ed that h—igr-, the inst ment voluntarily`f: iii'' TONT COMMISSION
SPERGER
(� i =,? MY COMMISSION#GG 353178
J '- , .� :October 6,2023
I'•,>:..'oP,'BondldhR�eSN bl� fkrtars
Signature of Notary Public,State of Florida .°'°""'"`°'a ..— ; -- • • (Type)
40
H:\Applications&Forms\Word&Excel Document Or;..s\201801001 Right-of-Way Easement Permit Application.docx Revision Date:10/1/18
- `,: REVOCABLE ENCROACHMENT AGREEMENT
.,y '' \ **ALL INFORMATION
City of Atlantic Beach HIGHLIGHTED IN GRAY
°; �' 800 Seminole Road,Atlantic Beach, FL 32233 Wir IS REQUIRED.
--v
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
'CY lrpid . Gippe 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 .
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
• 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.
k421146414. e• kitfille Date d7M/Z(o /.2(P1/
Property Owner/Agent (signed in presence of Notary Public)
STATE OF FLORIDA,COUNTY OF DUVAL
The foregoing instrument was acknowledged this day of ITA
pr`L l , 201J ,
by 1,-1 a 1--,-,-) ( d_ E..-.. C ( P lc) e____ ,who personally appeared before me and
(•rinted na = •f Signer)
ack •w edged tdip
- signed the instrument voluntarily for the purpose expressed in it.
44
A . •.
(� c i`
a._ 1�" Pte, TONIGINDLESPERGER Department Approval:
"MI NIP Signature of Notary Public, State if Floiida.�i','' mac., MY COMMISSION#GG 353178
PersonallyKnown ;'°; wpo= EXPIRES:October6,2023
[ ] ; ':f;o- ;� Bonded Thru Notary Public Undervvrtters
[ J Produced Identification(Type) _t_— Scott 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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- Land Surveyors,LLC
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PROPERTY ADDRESS:1909 MEALY STREET, ATLANTIC BEACH,FLORIDA 32233 SURVEY NUMBER:F1 .5036 •
BOUNDARY
BOUNDARY SURVEY
DUVAL COUNTYDUTTON ISLAND ROAD W
—N (CHURCH
(CHURCH ROAD-PER PIAT) ,
r ?5800'(P1 I LOT 1.BLK 1 . 11:)" E" 40/ .
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LANDS DESCRIBED N -
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REMAINDER OF LOT 2
.NOT INCLUDED-
S 6 25.0 3$ W T
_ S B9•Si73'E 7798'(A1f 17- it r 2 8 m W ¢ S�'-
12, ''(PI EAST 78.00'(D) o L
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onY •�' J ��
0 0 LOT 2 �s --- 45 o I �/
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=F- , z LOT CZ)
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Z ~ 71063 SD.FT 1
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PART OF L r(P) WEST 78.00'(D) . "2' r'P`
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LOT 5 N as"2r35 w 7e 99/Hl : 0.77 5 =l NO c /t",tf , .
Bl.K3 I REMAINDER OF LOT 3 0 024'W r–
u. a -NOT INCLUDED- I
$ $ LANDS DESCRIBED IN l t 1 3-50 sc
a 0 R V 6505,PG 2021 I
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1 75 ar(PI J
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t NL 25800'(P)
30 0 15 30
GRAPHIC SCALE(n Feet)
SURVEYOR'SOWN I
ROTES 1 inch=30')
FENCE OWNERSHIP NOT DETERMINED
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POINTS OF INTEREST:
SURVEYORS CERTIFICATION: NONE VISIBLE
I hereby certify that this Survey of the lands
�,ae 111 LFII% described hereon
and to the made of amy
representation
/ -,tN andunder my direct
supbelief i
/v 5646 •
"► and belief is a true and accurate representahon
I/ of said lands and meets the Standards of
704
/ Practice set forth m Chapter 5J-15.050 througn ,•?CACTA•.., 53-15.053,Florida Administrative Code, E6a.wW�^'��^4pursuant to section 472.027,Florida Statutes . �s y.vo.0 c Q �5ywl+aa7..xu:.41190 Fa:r,+aY pM'S+xe 1 Sod NFen.R]7911
'p STATEOF a This survey is not valid the signature an,:
Ow F'LORmA �S original raised seat of a Florida licensed survevc,
�J,y :),/;'4'
and mapper,except when the electronic
i �c sURvEr-O' signature and seal of a Florida licensed surveyor Florida Land AFFILIATE
and mapper is affixed hereto. Title Association.
MEMBERS
KENNETH 1.WAD FTA MEMBERS
Surveyor s a rA.Pva
w+.�:rrcoa4�50+6
.•d4 L.,..Surroyere,WC I RB4 S2
SEE PAGE 2 OF 2 FOR LEGAL DESCRIPTION
DATE OF SURVEY: 03/10/21 PAGE 1 OF 2-NOT VALID WITHOUT ALL PAGES
FIELD WORK DATE:2/24/2021
REVISION DATE(51:(REV1 3110/2021)