631 SELVA LAKES CIR DWAY21-0025 srt 'r,,, Building Permit Application
updared zo/9/ia
City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
r Ji3��r IS REQUIRED.
Phone: (904) 247-5826 Emai : Building-Dept@coab.us
Job Address: 6 3 I t1ez Permit Number: LOR ( Z I —00
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Legal Description "13-1/ i1 -15-7A L SoAvk LIZ'S U,ir1 Z 14- O/ RE# 1710Z7 -SSS k"
Valuation of Work(Replacement Cost)$ /(D f 00 0 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New DAddition Alteration DRepair ❑Move DDemo ❑Pool DWindow/Door
• Use of existing/proposed structure(s): ❑CommercialJ�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)
Describe in detail the type of wor-klto be performed: &i,t
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Cif Lit- Dikti.doA t (A# 14)6,
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Florida Product APPro(al# for multiple products use product approval form
Property Owner Information 61,1,0
Name ,t 4!I[: 11/ 44-l_ Address t 3/ 1 V '5
City 4,r , (fit I_ ,_ State it Zip ?i2.3.. Phone
E-Mail 5.4 .The "V` / �`� (� )
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company1� Qualifyin_ Agent If/- /VI '
Address 1 D � .e;, City 4 .a .. State L ip 3Z133
Office Phone q() � �?"]Z /1.24 Job Site Contact Number
State Certification/Registration# E-Mail it e /] r11e . 6)M
Architect Name&Phone#
Engineer's Name&Phone# VOA/Workers Compensation Insurer ,15e- 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 tallation 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 YOUR NOTICE OF COMMENCEMENT.
igna( e w r or Agent) (Signature of Contractor)
S'ned and sworn to(or a' it ed)before e this I (Say of Si ned and sworn to(ora -d)before /e thi� day of
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±E1111111` �
e . '.ta ) ign. Notary)
<i Y?gc,' TONI GINDLESPERGER ;'�e' TONI GINDLESPERGER
[ ]Personally Known OR •: ft MY COMMISSION#GG 353178 , 'ersonally Known OR MY COMMISSION#GG 353178
[ ]Produced Identification . EXPIRES:October 6,2023 I Produced Identification:.; :� EXPIRES:October 6,2023
onded Thru Nota Pubic Underwriters i 'S„,a�
Type of Identification: � �'' ry Type of Identification: .,,,,..•• Bonded Thru Notary Public Underwriters
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'\/ CITY OF ATLANTIC BEACH
r- 800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
(904) 247-5800
SURVEY AGREEMENT
NOTICE
All new projects creating more than 250 Square Feet of impervious surface or requiring on-site storm water
retention, including swimming pools, will require pre-construction and post-construction topographic surveys,
as required by COAB, Section 24-66 and described in Bulletin 2-18, Surveys. The surveys must be new
original documents, from a licensed surveyor, signed, sealed, and dated.
Other small projects, such as fences and construction less than 250 SF, will not require a new topographical
survey, but a current original-size survey with all relevant details is still needed. These surveys, when included
as part of a building permit application, must be complete, up-to-date, and original size and scale, as produced
by the surveyor.
Copies of old surveys lacking details or copies not of original size cannot be accepted. Building permit
applications with unacceptable surveys cannot be reviewed and the application will be returned to the
applicant.
Thank you for your cooperation in this matter.
AGREEMENT
I have read and understand the Notice above and affirm that the outdated survey I am
submitting is still accurate and complete, and all structures and impervious surfaces on the
property are shown on the survey.
I further understand that, if the survey is found to be inaccurate or incomplete, a $50.00 Plan
Resubmittal Fee will be charged; or if the permit has been issued, a Stop Work Order will be
posted with the associated $110.00 Fee.
JOB ADDRESS 3/ 61 k-
OWNER
or CONT CTOR (Print) d �/hG
Signator lrJP- �
Date
1 //
1
RIGHT-OF-WAY/ EASEMENT PERMIT APPLICATION **ALL INFORMATION
:_/:::g...H'- ----',, City of Atlantic Beach HIGHLIGHTED IN GRAY IS
800 Seminole Road, Atlantic Beach, FL 32233 REQUIRED.
PERMITTEE RESPONSIBLE FOR NOTIFYING 811 AND OBTAINING UTILITY LOCATES
Job Address (i;I � '�(� L4k3 (41(4 _- Permit Number
Contractor Inform tion
Company fd, � Qualifying Agent / ?077
Address / CityL Z 3
0 �l7 r ,�'�1,(�1 /y lw� /80/y4 State Zip �j
Phone Qty 377- 7LZG ��U_ Email i\nt—d Y:/ /4ij1 Le),-7--
State Certification/Registration#
Architect Phone Email
Engineer Phone Email
Workers Compensation Insurers ! i,_
j .t OR ExemptfExpiration Date rfey/7-7/
• 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 Bech or Flora Department of Transportation Standards and be performed under the
supervision of IL� ,y� / (Project Superintendent)
with (Company Name) .€2 /j, ',F,.11 1- ' Phone qQ it ' i7 /O &
• 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 Publ c Works Director shall be notified 24 hours prior to starting work and again immediately upon com•letion.
,( 7)/ADate (�
. rmitte (signed in presence of Notary Public)
STATE OF FLORIDA,COUNTY OF DUVAL /
The foregoing instrument was acknowledged this I day oft t i ;1 e ,20 7 l ,
by 0.4 g I . e- L. l!l _1~'1 , 4 -Q._ ,who personally appeared before me and
(printed name of Permittee)
=?0<I;PC �S
�.^, TC';�I G;NDLESPERGE
ack ow dged �t he/s - signed the instrument voluntarily for the purpose expressed in, :,t �.� `., f,,yGOt,'"v11SSI0N#00 353178
• ''.°24,;;;,,,,7,.,'1,-R:,::..7-'. .'IRES:October 6,2023 f
'. ; E:ondec Thru Notary Public Underwriters ii
[ ] Personally Known ype
Signature of Notary Public,State of Flom [ I Produced Identification(T )
H:\Applications&Forms\Word Documents\201801001 Right-of-Way Easement Permit Application.docx Revision Date:10/1/18
:-0-� REVOCABLE ENCROACHMENT AGREEMENT
' n� City of Atlantic Beach
**ALL INFORMATION
�, HIGHLIGHTED IN GRAY
800 Seminole Road,Atlantic Beach, FL 32233
IS REQUIRED.
'-OU r ,
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REVOCABLE ENCROACHMENT AGREEMENT by the City of Atlantic Beach, Florida, a municipal corporation organized and
existing der the law's the State of Florida, hereinafter referred to as"CITY" and
Na
(IL I f e 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 l ve1.A4ft.jf2,,,,,/gd�/ 4- �r wail/ .
Any facility maintained, repaired, erected, and/or installed in the exercise of the privilege grantedWmains 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 6 3/ It/it - -"5 ( ate- .
• 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
liabili ' ire hereby assumed by the USER.
A
Date 67/S7-71
Property Owner/Agent (signed in presence of Notary Public)
STATE OF FLORIDA, COUNTY OF DUVAL
The foregoing instrument was acknowledged this / _) day of n e , 20 Z.. i ,
by I vC..' g-1 t " L. LURL-1-. -€_ , who personally appeared before me and
• ted name of Signer)
ackno - iged t at l}e/ he signed the instrument voluntarily for the purpose expressed in it.
i��
c-„,,, -' Department Approval:
Signature of Notary Public, Sta`1(/te�f Florida ;;.!k.'Y°�k;,•,, TONI G:NDLESPERGER
2• A. '.c. MY COMMISSION#GG 353178
[ ] Personally Known '. ; ;,= EXPIRES:October 6,2023 i
[ ] Produced Identification (Type) �� • Williams,F°`'••• Bonded ThruNotary Public Underv,r Sc t Williams, Public Works Director
H:\Applications&Forms\Word Documents\20180831 Revocable Encroachment Agreement.docx Revision Date:8/31/18
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THE PROPERTY SHOWN HEREON APPEARS TO LIE W171-1/N FLOOD HAZARD FLORIDA, DOTE. a' A4 S SCALED LED FROM FLED
INSURANCE RATE MAP 4001 FOR THE CITY OF ATL. F34_44,
IS SHOW AS A COURTESY ONLY AND DOES NOT CONSTITUTE A CERTFCA770N OF O��ME INC.
TRI—STATE LAND SUR Y
5411 BA YMEADOWS WAY SUITE #2, JACKSONVILLE, FLORIDA 32256 (904) 731-7235
LEGEND BEARINGS BASED ON 17---1+'`/ LINE AS SHOWN.
:CNC. WON THIS SURVEY DOES NOT REFLECT OR DETERMINE Q IERSIIP.
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c'-^-' M l L5 414+) NUT VAL;U iW TNOUT 77-IE' S7GNATv7F_ AND 77-EE CIi';G! AL aA/SEC SCAL
Hca' OF A FLORIDA LICENSED SURVEYOR ,AND MAPPER.
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