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812 OCEAN BLVD RES21-0158 Building Permit Application Updated 10/9/18 .7: ':,--:! City of Atlantic Beach Building Department **ALL INFORMATION ,,,,,,.j 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY IS REQUIRED. Phone: (904) 247-5826 Email: Building-Dept@coab.us 812 Ocean Blvd Job Address: Permit Number: (--\E_- Z I -Cl --)E,) Legal Description 15-60 16-25-29E.40 Park Terrace A S/D PT Lot 1 RE# 170335-0000 Valuation of Work(Replacement Cost)$$87,000 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 prosect? ❑Yes(must submit separate Tree Removal Permit) ❑No Describe in detail the type of work to be performed: Install MEP, site,garage doors,front door,handrails and architectural finish items required by code in accordance with the provided plans Florida Product Approval# for multiple products use product approval form Property Owner Information Name David Reed Address 10898 Bridges Rd City Jacksonville State FL Zip 32250 Phone 904-874-6607 E-mail DavidReedECOS@gmail.com Owner or Agent(If Agent, Power of Attorney or Agency Letter Required) Contractor Information Name of Company Conserve,LLC Qualifying Agent Chester Kimes AddresS5060 Parete Rd S.,Jacksonville,FL 32218 CltyJacksonville State FL Zip32218 Office Phone 904-444-1141 Job Site Contact Number State Certification/Registration#CGc1523986 E-MaiICK'mes@ConServeLLC.com Architect Name& Phone# Engineer's Name& Phone# Workers Compensation Insurer Lon Insurance Company OR Exempt ❑ 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 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 OR AN ATTORNEY BEFORE RECORDING Y• : k • OF •M ENCEMENT. 7 (Signatu • of •wner or Agen ignature of Contractor) /� i ed and sworn to(or affi lb& d)before me this/ day of i ed and sworn to(ora it ed)b•ye 'e this ! day of V �I ,20Z ,by Li: Al O- ,I ` -- b ilt d!_!,,I _ �. - • ;o.:_ t ,ta•")ilMaiiiiik �( PrvC TG51 GiN^vL P �1 sY aean_axn.x.c:+nrf. �. • '� •" '- TONT G:NDLESPERGE� g. , MY COtJ�M11SS10ii#GG 202378 ii >9r;�, all :;tuber.6, , _ •, MY COMMISSION#GG 353178 Y pub!icUnderwritsrs ersonallyKnown. �; I;, • .. EXPIRES:October 6,2023 (''��rq�`tict$A �+i"'?±.-,:— _ter- [ ] Produced Identificd'ti:• -•�t�:� r 'I 9F'f`;°` Bonded Thru Notary Public Underwriters • n "cation: Q.cS oc-- e_r. : Type of Identification:y_ - — acv REVOCABLE ENCROACHMENT AGREEMENT City of Atlantic Beach **ALL INFORMATION ? HIGHLIGHTED IN GRAY . ►` 800 Seminole Road, Atlantic Beach, FL 32233 IS REQUIRED. r / REVOCABLE ENCROACHMENT AGREEMENT by the City of Atlantic Beach, Florida, a municipal corporation organized and existipEt, under the laws of the State of Florida, hereinafter referred to as "CITY" and L (J i c'� (e_Qcf 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 p!'i1A-e-.41 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 Off, 3(1 cics d r rl - • 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 hereb assume• by the x-17 r -r� — Date /61(0c-4--(C) ( Property •wner/Agent (signed in presence of Notary Public) STATE OF FLORIDA, COUNTY OF DUVAL r1 The foregoing instrument was acknowledged this /- day of , 20 / ( by ( )ctt/�c( t Q , who personally appeared before me and (printed name of Signer) ack wledged t/h,./she si ned the instrument voluntarily for the purpose expressed in it. Y C4- Department Approval: Signature of Notary Public, Sta o Florida ,,,,,P;,, TONIGINDLESPERGER [ ] Personally Known =2 . .°;_ MY COMMISSION#GG 353178 [ ] Produced Identification (Type) 9,F.••,;o1=, EXPIRES:October 6,2023 Scott Williams, Public Works Director 9F ,;.• Bonded Thru Notary Public Underwriters ama H:\Applications&Forms\Word&Excel Document Originals\20180831 Revocable Encroachment Agreement.docx Revision Date:8/31/18 NOTICE OF COMMENCEMENT State of (cDv'�ryl� Tax Folio No. County of 44✓4 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: Address of property being improved: (} /9 c,C Pa,., I I ' e'i( General description of improvements: 1N5-k I( AA PI CI-fie 3o - c)vv5 Fa+ t Owner: Da i(`e( RQ ,-i Address: /CfqS3' i3i-i4 i �l� r/�C 3.W Owner's interest in site of the improvement: Fee Simple Titleholder(if other than owner): Name: Contractor: (D), se 0, ,n)'( C I_ D l I Address: 5060 i -rek M�f S. ) C�Spi��l/(� 1 �� 3�1 Telephone No.: QOc/ //La Fax No: Surety(if any) /)/1),4/1-e____ Address: Amount of Bond$ Telephone No: Fax No: Name and address of any person making a loan for the construction of the improvements Name: NU 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: /J )i'& 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: /1/2.7N-e_ Address: Telephone No: Fax No: Expiration date of Notice of Commencement(the expiration date is one (1)year ;, - - ------- ----------- rent date is specified): *:,:c4 TONI GINDLESPERGER ;.: �•= :,: MY COMMISSION#GG 35317$ '•.W EXPIRES:October 6,2023 THIS SPACE FOR RECORDER'S USE ONLY OWNER • Bond.• hru Notary Public Underwriters i Signed: ( Date: I / j rJ Befor- - - is d. • Li) in the County of Duval,State 0' lorida,has personally app d WM. - - Notary Public at Large, ate • lorida, •' •f Duvd. My commission expires: Personally Known: - L ` or Produced Identification: ✓ Date CERTIFICATE OF LIABILITY INSURANCE 5/13/2021 Producer: Plymouth Insurance Agency This Certificate is issued as a matter of information only and confers no 2739 U.S. Highway 19 N. rights upon the Certificate Holder. This Certificate does not amend,extend or alter the coverage afforded by the policies below. Holiday, FL 34691 (727) 938-5562 Insurers Affording Coverage NAIC# Insured: South East Personnel Leasing, Inc. & Subsidiaries Insurer A: Lion Insurance Company 11075 2739 U.S. Highway 19 N. usurer B: Holiday, FL 34691 Insurer C. Insurer D: Insurer E: Coverages The policies of insurance listed below have been issued to the insured named above for the policy period indicated. Notwithstanding any requirement,term or condition of any contract or other document with respect to which this certificate may be issued or may pertain,the insurance afforded by the polities described herein is subject to all the terms,exclusions,and conditions of such policies. Aggregate limits shown may have been reduced by paid claims. INSR ADDL Policy Effective Policy Expiration Limits LTR INSRD Type of Insurance Policy Number Date Date (MM/DD/YY) (MM/DD/YY) GENERAL LIABILITY Each Occurrence $ Commercial General Liability Damage to rented premises(EA Claims Made ❑ Occur occurrence) $ Med Exp $ Personal Adv Injury General aggregate limit applies per: $ Policy ❑Project ElLOC General Aggregate $ Products-Comp/Op Agg $ AUTOMOBILE LIABILITY Combined Single Limit (EA Accident) $ Any Auto Bodily Injury All Owned Autos (Per Person) $ Scheduled Autos Hired Autos Bodily Injury (Per Accident) Non-Owned Autos $ Property Damage (Per Accident) $ EXCESS/UMBRELLA LIABILITY Each Occurrence IOccur ❑Claims Made Aggregate Deductible A Workers Compensation and WC 71949 01/01/2021 01/01/2022 x I WC Statu- I 1OTH- Employers'Liability tory Limits ER Any proprietor/partner/executive officer/member E.L.Each Accident $1,000,000 excluded? NO E.L.Disease-Ea Employee $1,000,000 If Yes,describe under special provisions below. E.L.Disease-Policy Limits $1.000,000 Other Lion Insurance Company is A.M.Best Company rated A(Excellent). AMB# 12616 Descriptions of Operations/LocationsNehicles/Exclusions added by Endorsement/Special Provisions: Client ID: 90-67-149 Coverage only applies to active employee(s)of South East Personnel Leasing,Inc.&Subsidiaries that are leased to the following"Client Company": Conserve LLC Coverage only applies to injuries incurred by South East Personnel Leasing,Inc.&Subsidiaries active employee(s),while working in: FL. Coverage does not apply to statutory employee(s)or independent contractor(s)of the Client Company or any other entity. A list of the active employee(s)leased to the Client Company can be obtained by faxing a request to(727)937-2138 or email certificates@lioninsurancecompany.com Project Name: ISSUE 05-13-21 (SS) Begin Date:1/4/2021 CERTIFICATE HOLDER CANCELLATION CITY OF ATLANTIC BEACH Should any of the above described policies be cancelled before the expiration date thereof,the issuing insurer will endeavor to mail 30 days written notice to the certificate holder named to the left,but failure to do so shall impose no obligation or liability of any kind upon the insurer,its agents or representatives. 800 SEMINOLE RD _ -— • ATLANTIC BEACH, FL 32233