221 Pine St ROW19-0020 Submittal riyLy;� City of Atlantic Beach APPLICATION NUMBER
5 Building Department
�L.�� a ned by the Building Department.)
' 800 Seminole Road 1 C A v _ - OZ0
E
Atlantic Beach, Florida 32233-5445 JUL , �O„ 1 V
Phone(904)247-5826 • Fax(904)247-5845 lJ rJ t s
ilio;;tTe E-mail: building-dept@coab.us to routed:
City web-site: http://www.coab.us BY:
APPLICATION REVIEW AND TRACKING FORM
Property Address: Z Z I Pi 0E_ - ( Department review required Yes No
Building
Applicant: t Q T A l..- HC)/Y1 C— RC�t-111/4:--) Planning &Zoning
ame\ Tree Administrator
Project: p s-r�-:('c._. ( V �2 0 �' J ublic Worr
ublic 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:
APPLI ATION STATUS
Reviewing Department First Review: pproved. ❑Denied. ['Not applicable
(Circle one.) Comments:
BUILDING <
PLANNING &ZONING
Reviewed .. : i / // •ate:
- .. - -....-
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
. F � RIGHT-OF-WAY/ EASEMENT PERMIT APPLICATION **ALL INFORMATION
`y�" 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 Q /Job Address f I STPermit NumberRow ( I -00 Z9
Contractor Information
Company ITA ( . 1140v Roo F(N LLC Qualifying Agent J1M N -7 PEDA (JP)
AddressZ9GS RAIN3OJ) 1�1 • City cri1C. 3N J\ll_. State t---L zip322J-7
Phone 32[ -'-6Z' 9 223 Email}
State Certification/Registration# CCC 331 0 6C •
Architect Phone? / Email
ne_�
Engineer PhoZ-6G(S Sr�838 Email
Workers Compensation Insurer .14C,E__OR Exempt n Expiration Date 12—/-311/
• 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 T\ranspo tation Standards and be performed under the
supervision of `/ �}�,�� P. -LE �S J Project Superintendent)
with(Company Name) '�nT Ai_ I-10VVM ROC) INC �,L.0 Phone(32_1�3L i °-1'5
• 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. lithe 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 Public Works Director shall be notified 24 hours prior to starting work and again immediately upon completion.
BEAN cti MAMiGa J Date -1 (10 f/ 1
Permittee(signed in pre n of tary Public)
STATE OF FLORIDA,COUNTY OF DUVAL
The foregoing instrument was acknowledged this ' 0 day of �U (\/ ,
by .Ji1J)N ( q sonally appeared before me and
(printed name o Permittee) tivj,.,
�: TONT GINDLESPERGER
'• '•` ._
acknowlec�ed that -,(she •igned t e instrument voluntarily for the purpose expressed in'�y; � _
l EXPIRES:COMMISSIO
OctNob#FFer 6,925951
2019
� R,(h bondedMY Thru Notary Public Undenvr'ters
[ ]Personally Known /_1 /� /'
Signature of Notar' Public, tate of Flor a [ ]Produced Identification(Type) 3u'-4&S-9 4
H:\Applications&Forms\Word&Excel Document Originals\201801001 Right-of-Way Easement Permit Application.docx Revision Date:10/1/18
• ,:'''''r" Building Permit Application Updated 10/9/18
rj
City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
-!1.119'' IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: 2L' P I i c-')-1-: Permit Number: R R. F.11 ( 0( 1 - (6S
Legal Description i Roo r RE#
Valuation of Work(Replacement Cost)$ Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration epair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial LiR'esidential
• If an existing structure, is a fire sprinkler system installed?: ❑Yeso
• Will tree(s)be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) o
Describe in detail the type of work to be performed: T-07-AL Ri -120,01= / I-k A(.A U I vjAy
Florida Product Approval# for multiple products use product approval form
Property Owner Information _ C
Name V A C I+M L ��L�- Address 222.--\ P I Kr- J_
City ArLkN-fl C -F Ac,14 State --L.. Zip .j22Z3 Phone clot ` ' 1.C]5-.a 'j671
E-Mail
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company TO TA,(. _ kOVN11t (2cD L t\€ Qualifying Agent J( } 2_
Address 29 8 RA1tve.0\A RD_ City JACK.30 I( State ►t Zip '372.11
Office Phone —321— S2_—" '122.3 Job Site Contact Number ??21 —31-( i -9795
State Certification/Registration#CCG 1330 4 77 E-Mail
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer BnidirtfriRt I NSt,S-fl NG OR Exempt❑ Expiration Date (a/31 fu9
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 wil performed to meet the standards of all the laws regulating
construction in this jurisdiction. I understand that a separate p it must be secured for ELECTRICAL WORK, PLUMBING,SIGNS,
WELLS, POOLS, FURNACES, BOILERS, , ERS,TANKS,and A CONDITIONERS,etc. NO ' . addition to the requirements of this
permit,there may be additional res ictions .•slicable to this roperty th- .y be fo din • public records of this county,and
there may be additional permits re. ired from 'ther:• • e I entiti . such as er • . agement districts,state agencies,or
federal agencies.
OWNER'S AFFIDAVIT: I certify that all the egoi _ •rm. on is accurate an. • all work will be done in mpliance with all
applicable laws regulating construction and z.
WARNING TO OWNER: YOU' ' a ILU • TO RECOROTICE OF MMENCE T MAY
RESULT IN YOUR PAYING TWICE FOR I PROVE TS 0 YOUR PR TY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOU E R OR AN a I ORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMEN .
J (S' nature of er or a;) _nature of Contractor)
Signed and sworn to(or affirmed)before me this day of Signed and orn t. .r affirmed)before me this day of
, by , by
(Signature of Notary) (Signature of Notary)
[ ]Personally Known OR [ ]Personally Known OR
[ ]Produced Identification [ ]Produced Identification
Type of Identification: Type of Identification: