197 Pine St Driveway Submittal . .,:'=;'"i-r, Building Permit Application Updated 10/9/18
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1 f' City of Atlantic Beach Building Department **ALL INFORMATION
"Mr 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
-urns'''. IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: i /' 17 �I rjo. �--.1*--. Permit Number:
Legal Description 5'4-)f 4-i'& "5 t``-1--r'd-Al Ddk14-1 o n 41,-- 1 6 RE#
Valuation of Work(Replacement Cost)$ 3.(c>O, t Heated/Cooled SF Non-Heat I E'VE
t
• Class of Work: Caw ❑Addition ❑Alteration DRepair ❑Move ❑Demo ❑Pool ❑Windo ooJUL 0 9 2021
• Use of existing/proposed structure(s): ❑Commercial QR'i?sidential
� BY:__
• If an existing structure, is a fire sprinkler system installed?: ❑Yes Et(o
• Will tree(s) be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) [)1Aio
Describe in detail the type of work to be performed:
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Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name 43-al.A41 c4- M - Ste'/l Address 1 P1,iJ< 5
City A-�- kilt t-tC_ )� _" State Zip �.2 3 3 Phone `L' 4:) --i-— % ( (� -4 Z`'1 '-
E-Mail 1 i`cam{-15`�(._?WA--,0 6) t� C.L.-6 I i b i
Owner or Agent(If Age'rh, Power of Attorn�or Agency Letter Required)
Contractor Information `
Name of Compan is, i' J It.,,,) r.• -c'1., < C1nVz-14e.Qu lif �`
Agent 't C1-)" c, ,\
Addres
117' 1 lZr✓1 ' Cif State Zip 3j LZv
Office Phone Cpm " 1{-2-(0 ` �72� Job Site Contact Number( L-1'O --- Ci��
State Certification/Registration#(3-c \\,bYiv2 E-Mail xc1-.E.S /11+5' r (-) } TO
Architect Name&Phone# J
Engineer's Name&Phone#
Workers Compensation Insurer OR Exemp Expiration Date 70
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 YOUR NOTICE OF COMMENCEMENT.
t' — � -- 0
64., gnuof Owner or ) ( 1
e of Contractor)
ortis
.igned and sworn to(or .ffi m:d)before me' i I •ay of Sig ed arid swo[�to�(or aff m • •ef. -,m- is 0 dayof
_ _ .�.. �A 4 ►► , e I"0 1 6G �,b All . Gly: '"e6A
Al LI I I WA
.,04.v.":,".,:-(1',N„;:''. _ TONI GINDLESPE - �I rm
,., :, MY COMMISSION#G-_> 71It ,.../".7;,,, . y _ _
-" '" • EXPIRES:October 6,2023
^,r•...•P: Public Underwriters I •o•. . ,; TONI GINDLES ER
':FOFe�°.� BOndedThNNotary �^r`•Y"•�
• sona y 'nown OR [ ]Personally Known OR =+: -4, :.,_ MY COMMISSION#GG 353178
Produced Identification [ ]Produced Identification ', '- •
;'Wit..• EXPIRES:October 6,2023
Type of Identification: Type of Identification: 1 • Bonded Thru Notary Public Underwriters
a■..z.r, RIGHT-OF-WAY/ EASEMENT PERMIT APPLICATION **ALL INFORMATION
'• ' t City of Atlantic Beach HIGHLIGHTED IN GRAY IS
� �r 800 Seminole Road,Atlantic Beach, FL 32233 REQUIRED.
L r a 91-
PERMITTEE RESPONSIBLE FOR NOTIFYING 811 AND OBTAINING UTILITY LOCATES
Job Address tci ' Pitdvc5 t. Permit Number
Contractor Information `
Company jj c. t to flf Ord 4 c IL.c Qualifying Agent
Address City State Zip
1
Phone q 6 q- 'f 2J2 - Z-2 2-0 Email 61.. -ki s 11 As o'' a itml_Co,' ii - t X44 i , c .i
State Certification/Registration# a-, _ 6 t i f Uz J
Architect Phone Email
Engineer Phone Email
Workers Compensation Insurer OR Exempt Expiration Date 2o" -
• 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 Transportation Standards and be performed under the
supervision of (Project Superintendent)
with(Company Name) Phone
• 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.
• T.tle Public Works Director shall be notified 24 hours prior to starting work and again immediately uonncompletion.
,,k _ Date �ti?S/ .2-1
Permittee(signed in presence of NO ry Public)
STATE OF FLORIDA,COUNTY OF DUVAL r
The foregoing instrument was acknowledged this ` 6 day of 0,r\ e ,20 1_ ( ,
by Kk...14A CSi- /‘"1 . s (tom ,who personally appeared before me and
(printed n e of Permittee)
ackno edg-. that h- he :ned the inst ument voluntaril rBJ° y�o TONT GINDERGER
O.. '!t. M� A^ ffsG 353178
EXPIRES:October 6,2023
0I"!E•iii F°P Bonded Thru Notary Public Underwriters
�— ersona ly Known
Signature of Notary Public,State of Florida . [ ] Produced Identification(Type) c„....
H:\Applications&Forms\Word&Excel Document Originals\201801001 Right-of-Way Easement Permit Application.docx Revision Date:10/1/18