358 4th St RESA21-0004 rev. 5-3-21 Revision Request/Correction to Comments **ALL INFORMATION
,40..,,,,,-;.,,,,, HIGHLIGHTED IN
I. "' City of Atlantic Beach Building Department GRAY IS REQUIRED.
\ 800 Seminole Rd, Atlantic Beach, FL 32233
\U � Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: RC- 11Z `0_r/)0/4-
yd
Revision to Issued Permit OR I I Corrections to Comments Date:
/-4.--g/2.
Project Address: 35-6 el S14"
Contractor/Contact Name: V ve)--f 4pj40f/(-f{rai,
Contact Phone: Email:
Description of Proposed Revision/Corrections:
AvAsvai,, ,-,--,-,,,_ 4i-i,cki,d
/fie. U out 40 Ikvi /d,� -j i- („0.,,,„.,,,
I affirm the revision/correction to comments is inclusive of the proposed changes.
(printed name)
• Will proposed revision/corrections add additional square footage to original submittal?
❑No ❑ Yes (additional s.f.to be added: )
• Will proposed revision/corrections add additional -ase in buil alu• to original submittal?
CI No []*Yes (additional increase in buildin: valu-. ,// ) (Contractor must sign if increase in valuation)
AW
......
*Signature of Contractor/Agen ,//
,or pr,
(Office Use Only)
❑ Approved ❑ Denied ❑ Not Applicable to Department Permit Fee Due$
Revision/Plan Review Comments
Department Review Required:
Building
Planning&Zoning Reviewed By
Tree Administrator
Public Works
Public Utilities
Public Safety Date
Fire Services Updated 10/17/18
3`wl ar" TREE & VEGETATION AFFIDAVIT FOR INTERNAL OFFICE USE ONLY
A
° � 1_s, City of Atlantic Beach PERMIT#
Community Development Department
v 800 Seminole Road Atlantic Beach,FL 32233
,J3 i' (P)904-247-5800
SITE INFORMATION
ADDRESS 65 - S-hce 6_1-
SUBDIVISION
SUBDIVISIION BLOCK LOT
RE# /6 9x.2 066 ('RESIDENTIAL ❑ COMMERCIAL ❑ OTHER
APPLICANT INFORMATION
NAME <\ Zen k! 4- PHONE#
ADDRESS 35 x 1.--\Th -litt a- CELL# q o y_53 v, .1,-1 Ire/
CITY 'OA- a \ L 3ca Lv_I STATE Ft.- ZIP CODE 3z:z 3 3
EMAIL V\oe_A-A V e 74 11 I ei,„., ( _ (� ki OWNER ❑ LEGAL AUTHORIZED AGENT
V
I affirm that I have reviewed the provisions of Chapter 23, "Protection of Trees and Native Vegetation", of
the Municipal Code of Ordinances for the City of Atlantic Beach Florida and/or I have participated in a pre-
application meeting with the Administrator of those regulations. Subsequently, I affirm that no regulated
trees and no regulated vegetation will be damaged, destroyed and/or removed from the above-described
property and/or adjacent properties including right-of-way.
I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IS CORRECT:Signature of Property Owner(s)or Authorized Agent
�" 1 \, i YS.I-eti1 Uov\V_ -I.. 23• 2`'Z(
SIGNA101RE OF APPLICANT PRINT OR TYPE NAME DATE
SIGNATURE OF APPLICANT(2) PRINT OR TYPE NAME DATE
APJ 0\
Signed and sworn before me on this Z 3 day of / 7°2by State of /�r�
kirS -f-eh / 4 ICI{ 8eh ((et+ County of 1
Identification verified: 00 L I C/4 VE'V L l end
Oath Sworn: Yes ❑ No
P
HERMEL G.ROSH Notary Signature
My Commission expires JL'1 / 70e 3
°.' MY COMMISSION#GG341673
`::
EXPIRES:JUN 04,2023 i
"XiBonded through 1st State Insurance
04 TREE AND VEGETATION AFFIDAVIT 03.01.20T8
JOB COPY rE,� ..a: - ,"
Building Permit Application (ByMike pees.?3 �om,Mu:.,:opt i-t'''` " ` 1
f.. City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
' t, IS REQUIRED. '
Phone: (904)p244t7-5826 Email:ilBiillcdlnf, Dt ptesodb.0
Job Address " . -���M k Per 11 N miler RESA2 : !I '-
Lob �y /ag-g 22,000O
}S legal Dccc pt or . ai.�S:••— �In--� i j_•i a.- .'( �RFN
Valuation of Work IRepiac 11'rit Cost)Si2-L/ O(j0, • Heated/Coole SF 61 N"on-Heated/Cooled
• Class of Work . New (PAddit.on 'ARrrat.on , Repair Move (_'Ortoo 'Pool I Window/Door
• Use of esisting!proposed struclurOs) 'Commercial 1 Residential
• If an eaist.ng structure is a fire sprinkler system installed) ' .Yes No
• WOO t'ce Sl uc rn•nOVI'rt <'1 ,15501 at ort with oto toned oro e(t) Yes most submit se•arate Tree Rin ova' Permit No
Describe in detail the type of work to be performed 1
/li->LC'iCbL cz401 her-#17)61/21 i a_t and ct &dfvU� .(c-le`i5/ 7r
F�or.da Prod�ict app-oval tf - for multiple products use product approve' form
Property Owner Information (�
Name -!� I rS .n 1:3e n Ler T Address 1)-1 3- mel vsf oy, - `Te_r r ac.Q if,V 2
co 2acLco N.%it t le State( 2.p 3-13.o-7 Phone '3 ir 4, 953_ 4,3 a/o
E Mai
Owner or Agent(If Arent Power of ,Attorney or Agency Letter Required) _
Contractor Information
Name o`Con'pars POt-�6-- _./.3U r/C� 66• Qualifying Agent PG CO /, )_/.
1 [�l v� / Crt yir-c_k- nvlbiG StateZip;J 727
Office Phonc 9,44 ---7� --fo Job Site C ntact Number J ' -LI5o -7-92-4
State Certit ca: mi Reg.stratcn aGc3 G You E MdIT dtt,lUo-V-ni? a o(S /G 1 u9 r-7,1 /•CU//
Architect Name& Phone a
Engineer's Name& Phone a _ i'';A .---502-:„..3-L � !N
�^
Workers Compensation Insurer i- i � OR Exempt Exp�rahon Date �
Appllcat ort s hereby made to obtain a perm.t to do the work and installations as indicated I certify that n• •.ork or installation has
cor'o erred p' or to the,sSuanCe Of a perm't and that all work will be performed to meet the standards of all the laws regulating
const'uct'on n this lurisd ct-on I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING,SIGNS,
�':ElI S POOLS. FURNACES BOILERS HEATERS.TANKS, and AIR CONDITIONERS,etc NOTICE In addition to the requirements of this
perm t 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 ail the foregoing information is accurate and that all work will be done in compliance w th,ill
applicable laws reeulat rig construction and toning
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 FINANCIN , CO •ULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECING YOU• x1400 F COMMENCEMENT.
1', ) drN,r r-n (Signature oft tractor)
iii
51 --d and 'a.o'n to to' af''rr rl di bc'o-e me this '' day of Signed and sworn to(or affirmed)before me thisl'_'_oay of
LI\n. 'YQ, by IV : 1'tl._v‘,/pill 111- NIt1201_, 20Zl- ,by __C1 t e-- C 1Zcat,e_5
is gnats, , of ,il
KIRSTIFJ SYRIONE ROYAL a
• Commiss,on N GG 318��0
VALERIE VVALLRATH I I 'snnallyKnown(1R .`' ExpiresA April
,, i P 2,2023
X ',Stateof Florida-Notary Public I roducedldent.i�i,iii 'I I1r�.idf'dTHUI r:ohs ,. E
r p,.r i i, . i, ', �fl.r�,e� My Comm ssionn 0 GExp e�0 T ePr of Idenhhl,ll an �Ra'�l> +.v..J.lw.v` i�'P
w 0 April 10, 2022