1855 Hickory Ln ACC18-0065 Paver Walkway Submittal 11Alt;y City of Atlantic Beach APPLICATION NUMBER
1 r � Building Department (To be assigned by the Building Department.)
800 Seminole Road � ,�� �� 5
C
9.* 0 ECE Atlantic Beach, Florida 32233-5445 1VE
[}Phone (904)247-5826 • Fax(904)247-5845
"�or! >%' E-mail: building-dept@coab.us ate routed: I Z/6", 3
City web-site: http://www.coab.us DEC 2��
APPLICATION REVIEW ►ND TRACKING FORM
Property Address: l gs k 'etc O EL( L.K) DeQartment review required Yes No
KBu
Applicant: k)C Planning &Zoning
Tree Administrator
Project: 11 c f y ublic Works
/ Public Utilities
Public Safety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: /Approved. ❑Denied. I 'Not applicable
(Circle one.) Comments:
BUILDING
PLANNING &ZONING Reviewed by.,...1126,?4,2Date: aV`0 '/u
TREE ADMIN. Second Review: (Approved as revised. ❑Denied. (Not applicable
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. (Denied. ❑Not applicable
Comments:
Reviewed by: Date:
Revised 05/19/2017
ot—vi City of Atlantic Beach APPLICATION NUMBER
�s Building Department (To be assigned by the Building Department.)
A ' 800 Seminole Road ' 1
;5_. �� Atlantic Beach, Florida 32233-5445 -
Phone(904)247-5826 - Fax(904)247-5845 ��jj
J;; 9� E-mail: building-dept@coab.us Date routed: 1 ., / C"Th
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: I ES k ICic0 LyLK, Department review required Yes -No
K
Applicant: ��TC LC_.- i I Planning &Zoning
Tree Administrator
Project: Pri&i� v� c\ u<kk) y c ":rublic Works-j)
Public Utilities
Public Safety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
St. Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: Rckpproved. ❑Denied. fNot applicable
(Circle one.) Comments: , C-
BUILDIN 'n�J D
PLANNING &ZONING Reviewed by: i/Y1) Date: i -//-/ ev
TREE ADMIN. Second Review: [Approved as revised. ❑Denied. ❑Not applicable
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date: _
FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied. ❑Not applicable
Comments:
Reviewed by: Date:
Revised 05/19/2017
d •IPS,,, Building Permit Application FFA - ----, Updated12/8/17
I
s u = City of Atlantic Beach
�,� ' 800 Seminole Road,Atlantic Beach,FL 32233
RtkiitrA
Phone:(904) 47-5826 Fax:(904)247-5845
Job Address: f 3 _ Permit Number: R - • O i.
Legal Description 31—Zt O'1`Zs`Zw "S.�ctf
r 44.,L un,fi2-1 ' Id (.j kRE# 1-170e9 -/Or
Valuation of Work(Replacement Cost)$ 5600 00 _ Heated/Cooled SF Non-Heated/Cooled
• Class of Work(Circle one): New Additio Alteratio Repair Move Demo.__Pool Window/Door
v
• Use of existing/proposed structure(s)(Circle one): Commercial Residential i
• If an existing structure,is a fire sprinkler system installed?(Circle one): Yes NoN/A__
• Submit a Tree Removal Permit Application if any trees are to be removed or Affidavit of No Tree Removal
Describe in detail the type of work tobe performed: -(-
R.0/1115Ve- (Itt& 4z4
f1 /çJ4i5 . -moi, 11 c )w// tfnd�4 -}0 6/00 ')-i i4I it cr
Florida Product Approval# for multiple products use product approval form
Property Owner Information ryrt
Name: 'dn.g PhAirr Address: I ONS V Kiri
City 4iviM, State rL Zip 3 LI- 3) Phone 3/ '$I Z
E-Mail ` ",+,n 75V( &/10✓ •,-)el-
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company: / '/ /. Qualifyi g Agent^ `
Address (Q , / (7 0 r City A;/ .A 7 d_ Zip 312-3
Office Phone CIO(( 3 7 (` 7_ p Job Site/Contact Number WI ;/
State Certification/Registration# E-Mail 1P-- (F 4 ( i i1 f' to,
Architect Name&Phone#
Engineer's Name&Phone# _
Workers Compensation Or\ 7-:It (4'ri Tr✓Sl') CI /•)(J 119
Exempt/Insurer/Lease Employees/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 regulationg
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.
C C�1 t /..00.-4,11111110.19.-
(Signature
-
(Signature of Owner or Agent) dr' .r (Signature of Contractor)
(includi •: •ntractor)
ed and sworn to(or affi before e hic�day of :•ed and sworn to(or affirmed)befo a me tits--5day of
y
,, ,,by I AA,ka _4 O_ t,b GZ`k-\ -Cf Q a
db _JMEI_ ,d ,NI F P
TONI GINDLESPER• 11�i a e of No k ty) l .- atu>•a o'F;Notiiy)
r�% MY CC)MkrSION#FF 92 ;1 I
c` nber6,20i9
( ]Personally Known�Ltunderwnte s [ ]Personally Known OR
',3:,,,...i.:_—.1.„.. ,:-- .. - ---:- r, [/]Produced Identification
Type of Identification: Air ,OQ—2-O 4-—40—VDZ`Y.'�entification: ��
dr.
MAP SHOWING BOUNDARY SURVEY OF
LOT 16, ACCORDING TO THE PLAT OF "SELVA MARINA UNIT NO. 12—C REOATrf,Atl .1i c1 DED IN
PLAT BOOK 37, PAGE 29 OF THE CURRENT PUBLIC RECORDS OF DUVAL`WNW, 7 aeApartment
This approval verifies compliance with applicable
CERTIFIED TO: EDNA D. MAIN, zoning, subdivision and other local land
development regulations, but does not constitute
STEWART TITLE OF JACKSONVILLE, INC., approval for the issuance of permits. Compliance
WACHOVIA MORTGAGE COMPANY with Florida Building Code and all other applicable
ust
AND WATSON & OSBORNE TITLE SERVICES, I„local,be Stateverified by and Federal
signature permittingofitheCity requirementsofAtlantic
m
Beach Building Official prior to the issuance Of a
Building Permit. %%�� �
Z e,--e,--/-" /5 Approved By' ��` ��,, !!�•:J�L:.������" /4"-
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