1772 OCEAN GROVE DR RFNC21-0118 Building Permit Application Updated l0/9/18
:-.s° 'C., City of Atlantic Beach Building Department **ALL INFORMATION
/ 800 Seminole Road, Atlantic Beach FL 32233 HIGHLIGHTED IN GRAY
o't}�r IS REQUIRED.
Phone: ,(904) 247-5826 Email: Building-Dept@coab.us �j
Job Address: /991 (es/M1 6,Ni a A- �41'L PC/1 31233 Permit Number: l�F I\\C�) - Ott g
Legal Description Lor 24,t ttiurf nor kti. 30/_ OC'A,J 6-oMti 0rtr 1-n0, Z 1 Pi rZL)1 1'.? RE# g9()/q— [i;Cc
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Valuation of Work(Replacement Cost)$ /I�/t1 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration 94Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial NResidential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes ❑No
• Will tree(s) be removed in association with proposed project? EIYes(must submit separate Tree Removal Permit) [ 'No
Describe in detail the type of work to be performed:
P_epl'4,1,5 4€c picas oit ie4 aiikd n DA porko p tope did
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name 1%- -1-06/k) Address /9)Z OCb�Q� �=!
6 4E: ). /L /
City 1%-lir
/C- (�E4C/( State F Zip 3 ,2�-3 J1 Phone 4/0g - Val-(O34-Sv
E-Mail ZQf..hoTD$/al) (.-6/1{AIL, en's--
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company Qualifying Agent
Address City _/ State Zip
Office Phone Job Site Contact Number
State Certification/Registration# _ E-Mai✓
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer OR Exempt o Expiration Date
Application is hereby made to obtain a permit to o the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit d that all work will be performed to meet the standards of all the laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING,SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS,TANKS,and AIR CONDITIONERS,etc. NOTICE: In addition to the requirements of this
permit,there may be additional restrictions applicable to this property that may be found in the public records of this county, and
there may be additional permits required from other governmental entities such as water management districts,state agencies,or
federal agencies.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECO/-NG YOUR NOTICE OF COMMENCEMENT.
ignature of Owner or Agent) (Signature of •ntractor)
igned a d sworn to(or aff'0!)before met is' da of , Signed and sworn to(or affi ed)before me this day of
dostatim ma
a TM, i. . (Signature of Notary)
Rts
< Y.. TORI GWDLESPER'GER
[ ]Personally Known OR '�'' MY CO X11 g� � GG O
[ ]Produced Identification t . '':,',....,,1&,..,,;7*E ��4u EXP ro Esd6Id ificat n
Type of Identification: r
1edTha t$f� ttlA
Owner Builder Affidavit **ALL INFORMATION
}" ,i-,,,,,,,,- ,*,Alli \ HIGHLIGHTED IN
`a City of Atlantic Beach Building Department GRAY IS REQUIRED.
p
'' 800 Seminole Rd, Atlantic Beach, FL 32233
J
Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:
I. FLORIDA STATUTES;CHAPTER 489, FLORIDA STATUTES, PART 1"CONSTRUCTION CONTRACTING" REQUIRES
OWNER/BUILDER TO ACKNOWLEDGE THE LAW:
DISCLOSURE STATEMENT FOR SECTION 489.103(7), FLORIDA STATUTES:
STATE LAW REQUIRES CONSTRUCTION TO BE DONE BY LICENSED CONTRACTORS. YOU HAVE APPLIED
FOR A PERMIT UNDER AN EXEMPTION TO THAT LAW. THE EXEMPTION ALLOWS YOU,AS THE OWNER
OF YOUR PROPERTY,TO ACT AS YOUR OWN CONTRACTOR EVEN THOUGH YOU DO NOT HAVE A
LICENSE.
YOU MUST SUPERVISE THE CONSTRUCTION YOURSELF.
YOU MAY BUILD OR IMPROVE A ONE OR TWO FAMILY RESIDENCE OR A FARM OUTBUILDING. YOU MAY
ALSO BUILD OR IMPROVE A COMMERCIAL BUILDING AT A COST OF$25,000.00 OR LESS.
THE BUILDING MUST BE FOR YOUR USE AND OCCUPANCY. IT MAY NOT BE BUILT FOR SALE OR LEASE.
IF YOU SELL OR LEASE A BUILDING YOU HAVE BUILT YOURSELF WITHIN ONE YEAR AFTER THE
CONSTRUCTION IS COMPLETE,THE LAW WILL PRESUME THAT YOU BUILT IT FOR SALE OR LEASE, WHICH
IS IN VIOLATION OF THIS EXEMPTION.
YOU MAY NOT HIRE AN UNLICENSED PERSON AS YOUR CONTRACTOR. YOUR CONSTRUCTION MUST
BE DONE ACCORDING TO THE BUILDING CODES AND ZONING REGULATIONS.
IT IS YOUR RESPONSIBILITY TO MAKE SURE THAT PEOPLE EMPLOYED BY YOU HAVE LICENSES
REQUIRED BY STATE LAW AND BY COUNTY OR MUNICIPAL LICENSING ORDINANCES.
II. INJURY LIABILITY;SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE,THE BUILDING DEPARTMENT
SUGGESTS WORKER'S COMPENSATION INSURANCE BE PURCHASED. .
III. IRS WITHHOLDING; OWNERS HIRING WORKERS BECOME EMPLOYERS AND SHOULD ALSO OBSERVE IRS WITHHOLDING
TAX AND/OR FORM 1099 REQUIREMENTS ON THE WORKERS THEY EMPLOY ON THEIR IMPROVEMENT TRADES.
IV. PENALTY; UNLICENSED CONTRACTORS CANNOT BE EMPLOYED UNDER ANY CIRCUMSTANCES. OWNERS BEING SUBJECT
TO$5,000 PENALTY UNDER FLORIDA STATUTE NO. 455-228(1). AN "OCCUPATIONAL LICENSE" IS NOT ADEQUATE. THE
OWNER SHOULD PHYSICALLY SEE THE COUNTY"CERTIFICATE OF COMPETENCY" OR THE FLORIDA"CONTRACTORS
CERTIFICATE"TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. CONTACT THE BUILDING DEPARTMENT(904-
247-5826 OR BUILDING-DEPT@COAB.US) IF IN DOUBT.
V. ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE STATEMENT AND THAT I
COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN OWNER-BUILDER PERMIT.
Job Address: /79Z QC /l) 6/10 VE- D 2 M-TLAA17C 13, 3a cW 3,00733
Owner Name: /gI2 (-t TO 0/&/ /PPhhonne Number: 9Dy i/o? o4364
Mailing Address: l 91 Z 061-../1/0 (-4✓i.M- City: 47Z4,Une i3t-tT State: FL Zip: 3a?33
Notarized Signature of Owner /at i_
Tha oing instr�iment was acknow edged before me this_'3day o#, 1 , 207`in the State of Florida, County
01r -
Signature of Notary Public ..� _e____ .1...__-/ i--
[ ] Personally Known OR [ ] Produced Identification!
Type of Identification: ` L
Updated 10/24/18
,,ot�Hv,au •.: TCNI GINDLESPERGER
z, ,•. .= MY COMMISSION#GG 353178
°x t, EXPIRES.October 6,2023
op;
.,,oFF�,. Bondad Thru Notary Public Underwritors
:-s-A`ri REVOCABLE ENCROACHMENT AGREEMENT
*4\ City of Atlantic Beach **ALL INFORMATION
if 800 Seminole Road,Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
'
" IS REQUIRED.
REVOCABLE ENCROACHMENT AGREEMENT by the City of Atlantic Beach, Florida, a municipal corporation organized and
existing under the laws of the State of Florida, hereinafter referred to as"CITY"and
/,,.Iz t j Tt2//W 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 FW CE. 12-F.� I12-
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 1992 DC6AA) C1201/t DA A TM MY- act/ 32033
• 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
liablit are hereby a umed by the USER.
Date ,P - / zv Z f
Property Own r/Age signed in presence of Notary Public)
STATE OF FLORIDA,COUNTY OF DUVAL i
The foregoing instrument was acknowledged this T day of �P , 20 -p.l ,
........___
by {P C ' obit, ,who personally appeared before me and
pri ed name of Signer)
acCkno I ged thae/stye signed(the instrument voluntarily for the purpose expressed in it.
""„c_ • Department Approval:
Signature of Notary Public,State of lor' a ra‘`•�xi*. TONT GINDLESPER
• 353' : MY COMMISSION#GG 353178
PersonallyKnown .
� � ;,r ��..P EXPIRES:October 8,2023
(Type) ), L '•.f.i,l?•' Bonded Thru Notary Public Underwriters
[ ] Produced Identification T e Scott Williams, Public Works Director
H:\Applications&Forms\Word Documents\20180831 Revocable Encroachment Agreement.docx Revision Date:8/31/18
).:' 1'''', Fence Addendum Updated 1/14/2021
J
City of Atlantic Beach Building Department
,,:�. 800 Seminole Road, Atlantic Beach, FL 32233 PERMIT#
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: Date:
iinl QCMA) 61/20VE v)- 304733 0/ - 13- -29
Property Type: Lot Type/ Features:
f$ Residential c29 One Street frontage (interior lot)
❑ Commercial 0 More than one street frontage(corner lot,through lot,
etc.)
❑ Swimming Pool
Fence Material: Fence Height (select all that apply):
W Wood 0 Four Foot (4ft)
❑ Chain Link yi Six Foot(6ft)
❑ Vinyl 0 Other
❑ Block/Stone (Plan details required for footings and/or
retaining walls)
❑ Other
Fence Location:
Please submit an accurate and current boundary survey showing all existing improvements(including building footprint,
driveway,swimming pool, etc.) and location of fence/wall and any gates. Plan details required for block wall footings and/or
retaining walls and any portion or fencing above 6ft in height.
Will the fence be built in an easement?
Yes (must submit separate Revocable Encroachment Agreement)
❑ No
Will tree(s) be removed in association with proposed project?
❑ Yes (must submit separate Tree Removal Permit)
4 No
Conditions of Approval:
• Roll off container company must be on City approved list. Roll off container cannot be placed on City right-of-way.
• All old fencing and debris must be removed from job site by contractor or homeowner.
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.
05/06/2804 14:13 9840885352
FJBDM PAGE 02/03
•
MAP SHOWING SURVEY OF
THE PLAT BOOK 20,OPA E 20 OFLOT
THE2CURRENT UBUC RECORDS OP WALOCOUNTY
•
y 1° 2,0 '4°
SCALE 1" + 20' 1
18th STREET
80' EMIT OF WAY
LOT 42 3,I31 • O
e' LASEMENT 0
rn
RESERVED(8'PLAT) Lor 27 ,
illa,
1 (N ee'19'02' E 112.17' IRON TO IRON) ]
I N 86'13'18" E 125.00' 1n Z
l u ian WA-
_
A- '
i'11
eataat.►u - P. THE NORTH 30.00 FEET OF LOT 2e pq W 0 ffi ^
wm.'aawUM,�i, I'8 g x. 33.8• V'
p.F17:44,11.41.7/044
it
C ( CONCRETE FOUNDATION o• ' S
O .1.
re A. I* 5WL01NO UNDER CON31 '0CRON _ 1e.e'
Lor 43 I f atT„ , ° S 86'13'18" W 125.00' '��"�' C7
� I rwc to ri 1,
1 1 I LAT 1e IXCEPT (S et19'02'W 121.1X FIELD) is t Wnp
o
• I•I. I . THE NORTH 30.00 FLET t ' ' `7 -] *,p '
0,`�. im 4 4 / ( 7' vI '11-1
.3 I I' I I- (b t i'FOUND IRON TO FOUND IRON” _ - t moN
GNI I i- Faaoc,L.
--. et ,a'71H wai, (125.00') 1
l"°� 1
• •`«'m Vt' 'I I I
on.ro0.0
LOT 44 � � LOT 25 1
I . I
•
NOTES:
. e THIS IS A BOUNDARY SURVEY.
s REAR/NOS ME BASED ON THE EASTERLY
LINE OF LOT 2e BONO NORTH O3.46'42'
WEST AS PER MAT,
o NO AUILWNO RESTRICTION LINES AS PER
PLAT,ASEMDIT3 AS PER PUT. THIS SURVEY WAS MADE FOR THE BENEFIT OF
ICJ PROPERTIES, INC.; FORD JETER BOWLUS
THE PROPERTY SHOWN HEREON APPEARS TO LIE DVSS & MORGAN, PA.
IN FLOOD ZONE 'X" (AREA OUTSIDE THE 500
YEAR F1.000 PLAIN) AS WELL AS CAN BE
DETERMINED FROM THE "FLOOD INSURANCE RATE
MAP" COMMUNITY-PANEL NUMBER 120075 0001
D. REVISED ON APRIL 17, 1989 FOR THE CITY
OF ATLANTIC BEACH. FLORIDA.
NOT VN10 WI114OtrT THE SIGNATURE ANO THE N W. 190ATWRiTIT, P.S.M.
ORC:NAL RAISED SEAL or A FLORIDA LICENIIIO FLORIDA UC. SURvEYOR and MAPPER No. LS 3295
SURVEYOR AND MAPPER.'
NOOVFlED LAT NUMBERS - DECEMBER 17, 2003 FLOIIDA UC. SURVEYWO k MAPPING BUSINESS NI. LB 3872
-CHECKED eY:—_ l BOATWRIGHT LAND SURVEYORS, INC. DA
DRAWN 9Y: PNc Naaw1tk. .2497
FILE: 2003-13520 1300 ROBERTS DRIVE, JACKSONVILLE BEACH, FLORIDA 241-8550 SHEET I_.OF_L
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