HomeMy Public PortalAbout11-0283 GainesDATE ISSUED: 05 -12 -2011
WORK DESCRIPTION
WORK LOCATION
OWNER NAME
ADDRESS
CITY, ST, ZIP
PHONE NUMBER
CONTRACTOR NAME
ADDRESS
CITY STATE ZIP
FLOOD ZONE
BUILDING VALUATION
SQUARE FOOTAGE
OCCUPANCY TYPE
TOTAL FEES CHARGED
PROPERTY IDENTIFICATION #
PROJECT VALUATION
CITY OF TYBEE ISLAND
BUILDING PERMIT
PERMIT #: 110283
REPLACE ROOF /WNDW; ENCL PORCH /TOILET
16 PALMWOOD ST
LISA GAINES
313 MONTAUK DR
RICHMOND HILL GA 31324 -4908
LISA GAINES
313 MONTAUK DR
RICHMOND HILL GA 31324 -4908
P
$ 186.00
$13,500.00
TOTAL BALANCE DUE: $ 186.00
It is understood that if this permit is granted the builder will at all times comply with the zoning, subdivision, flood control, building, fire,
soil and sedimentation, wetlands, marshlands protection and shore protection ordinances and codes whether local, state or federal, including
all environmental laws and regulations when applicable, subsequent owners should be informed that any alterations to the property must be
approved by the issuance of another building permit. Permit holder agrees to hold the City of Tybee Island harmless on any construction
covered by this permit.
This permit must be posted in a conspicuous location in the front of building and protected from the weather. If this permit is not posted
work will be stopped. The building contractor will replace curb paving and gutter broken during construction. This permit will be voided
unless work has begun within six months of the date of issuance.
Signature of Building Inspector or Authorized Agent:
P. 0. Box 2749 - 403 Butler Avenue, Tybee Island, Georgia 31328
(912) 786 -4573 - FAX (912) 786 -9539
www.cityoftybee.org
CITY OF TYBEE ISLAND, GEO1..,_,1A
APPLICATION FOR BUILDING PERMIT
I
Location: /6 PA -1_04 Lc 000 f3Q PIN # L/ -000 .1 - 19 00
NAME
ADDRESS
TELEPHONE
Owner
I S A.
Ci vQ j
/ � h it fs-ter /-1, c L�
`212_ - 227 -V7V9
Architect
or Engineer
p/,k
Building
Contractor
20.t -
/�
was
(4(,
4 boa „c 1,k_
`712.-( 7 -/IAL
(Check all that apply)
❑ Repair
Renovation
ij Iinor Addition
❑ Substantial Addition
❑ Other
E residential
• Ingle Family
❑ Duplex
n Multi - Family
n Commercial
❑ Footprint Changes
❑ Discovery
in Demolition
Details of Project: r / p f 4.ce_ c )..• ALA. i lOs� c4 r
n,oT 7.Zoo
Estimated Cost of Construction: $ / s--6) ”
L' .LJ 33 r'
? orb
Construction Type (Enter appropriate number)
(1) Wood Frame (4) Masonry (6) Other (please specify)
(2) Wood & Masonry (5) Steel & Masonry
(3) Brick Veneer
Proposed use: exrc�� `X$ ` �I�r�.l�- LJ: t-ti P,`.t �-�lJ 51v�� r 4-S S 4� jel-
Remarks:
ATTACH A COPY OF THE CERTIFIED ELEVATION SURVEY OF LOT and complete the
following information based on the construction drawings and site plan:
ki
# Units IA # Bedrooms Bathrooms
Lot Area Living space (total sq. ft.)
# Off - street parking spaces
Trees located & listed on site plan
Access:
Driveway (ft.) With culvert? With swale?
Setbacks: Front Rear Sides (L) (R)
# Stories Height Vertical distance measured from the average adjacent
grade of the building to the extreme high point of the building, exclusive of chimneys, heating
units, ventilation ducts, air conditioning units, elevators, and similar appurtances.
j LW) T t�,� iZ Per-5 i AAt) l i A41-}f
During construction:
On -site restroom facilities will be provided through e J— rv,), ,'� h ,, •
On -site waste and debris containers will be provided by bc,, Q„,
Construction debris will be disposed by by means of
2 n ( - c• L-Q •
I understand that I must comply with zoning, flood damage control, building, fire, shore
protections and wetlands ordinances, FEMA regulations and all applicable codes and regulations.
I understand that the lot must be staked out and that the stakes will be inspected to ensure that the
setback requirements are met. I understand also that a certified plot plan showing elevation must
be attached to this application and that an as -built elevation certification is due as soon as the
habitable floor level is established. Drainage: I realize that I must ensure the adequacy of
drainage of this property so that surrounding property is in no way adversely affected. I accept
responsibility for any corrective action that may be necessary to restore drainage impaired by this
permitted construction.
Date: Ste— If — I(
Signature of Applicant:
Note: A permit normally takes 7 to 10 days to process.
The following is to be completed by City personnel:
Zoning certification
Approved rezoning/variance?
NFIP Flood Zone
Street address and number: New Existing
Is it in compliance with City map?
If not, has street name and /or number been reported to MPC?
FEMA Certification attached
State Energy Code Affidavit attached
Utilities and Public Works:
Describe any unusual finding(s)
Access to building site
Distance to water main tap site
Distance to sewer stub site
Water meter size
Storm drainage
Approvals:
Zoning Administrator
Code Enforcement Officer
Water /Sewer
Storm /Drainage
Inspections
City Manager
Signature
Date
FEES
Permit
Inspections
X13
411
Water Tap
Sewer Stub
Aid to Const. '3 Z
TOTAL
LEAD -BASED PAINT
Adapted from http: / /www.epa.gov /lead /pubs /renovation.htm. Please use that site to access the following information.
Information for Property Owners of Rental Housing, Child- Occupied Facilities
Property owners who renovate, repair, or prepare surfaces for painting in pre -1978 rental housing or space
rented by child -care facilities must, before beginning work, provide tenants with a copy of EPA's lead hazard
information pamphlet Renovate Right: Important Lead Hazard Information for Families Child Care Providers,
and Schools. Owners of these rental properties must document compliance with this requirement. EPA's sample
pre- renovation disclosure form may be used for this purpose.
After April 22, 2010, property owners who perform these projects in pre -1978 rental housing or space rented
by child -care facilities must be certified and follow the lead -safe work practices required by EPA's Renovation,
Repair and Remodeling rule. To become certified, property owners must submit an application for firm
certification and fee payment to EPA. The Agency has up to 90 days after receiving a complete request for
certification to approve or disapprove the application.
Property owners who perform renovation, repairs, and painting jobs in rental property should also:
• Take training to learn how to perform lead -safe work practices.
• Learn the lead laws that apply regarding certification and lead -safe work practices beginning in April 2010.
• Keep records to demonstrate that you and your workers have been trained in lead -safe work practices and that you followed lead
safe work practices on the job. To make recordkeeping easier, you may use the sample recordkeeping checklist that EPA ha
developed to help contractors comply with the renovation recordkeeping requirements that took effect April 2010.
• Read about how to comply with EPA's rule in the EPA Small Entity Compliance Guide to Renovate Right.
Read about how to use lead -safe work practices in EPA's Steps to Lead Safe Renovation, Repair and Painting.
Information for Homeowners Working at Home
If you are a homeowner performing renovation, repair, or painting work in your own home, EPA's RRP rule does not cover your project
However, you have the ultimate responsibility for the safety of your family or children in your care. If you are living in a pre -1978 homy
and planning to do painting or repairs, please read a copy of EPA's Renovate Right: Important Lead Hazard Information for Families, Chil
Care Providers, and Schools lead hazard information pamphlet. You may also want to call the National Lead Information Center at 1 -800
424 -LEAD (5323) and ask for more information on how to work safely in a home with lead -based paint.
Information for Tenants and Families of Children under Age 6 in Child Care Facilities and Schools
As a tenant or a parent or guardian of children in a child care facility or school, you should know your rights when a renovation job i
performed in your home, or in the child care facility or school that your child attends.
• Before starting a renovation in residential buildings built before 1978, the contractor or property owner is required to have tenant
sign a pre- renovation disclosure form, which indicates that the tenant received the Renovate Right lead hazard informatio
pamphlet.
• Beginning in December 2008, the contractor must also make renovation information available to the parents or guardians c
children under age six that attend child care facilities and schools, and to provide to owners and administrators of pre -1978 chit
care facilities and schools to be renovated a copy of EPA's Renovate Right: Important Lead Hazard Information for Families, Chil
Care Providers, and Schools lead hazard information pamphlet.
Information for Contractors
As a contractor, you play an important role in helping to prevent lead exposure. Ordinary renovation and maintenance activities can creat
dust that contains lead. By following the lead -safe work practices, you can prevent lead hazards. Contractors who perform renovatior
repairs, and painting jobs in pre -1978 housing and child- occupied facilities must, before beginning work, provide owners, tenants, an
child -care facilities with a copy of EPA's lead hazard information pamphlet Renovate Right: Important Lead Hazard Information for Families
Child Care Providers, and Schools. Contractors must document compliance with this requirement. EPA's pre- renovation disclosure form ma
be used for this purpose. Understand that after April 22, 2010, federal law will require you to be certified and to use lead -safe wor
practices. To become certified, renovation contractors must submit an application and fee payment to EPA. See: Application for fin
certification. The Agency has up to 90 days after receiving a complete request for certification to approve or disapprove the application.
Contractors who perform renovation, repairs, and painting jobs should also:
• Take training to learn how to perform lead -safe work practices.
• Find a training provider that has been accredited by EPA to provide training for renovators under EPA's Renovation, Repai
and Painting (RRP) Program. Please note that if you previously completed an eligible renovation training course you ma
take the 4 -hour refresher course instead of the 8 -hour initial course from an accredited training provider to become
certified renovator. Click here for a list of eligible courses.
• Provide a copy of your EPA or state lead training certificate to your client.
• Tell your client what lead -safe methods you will use to perform the job.
• Learn the lead laws that apply to you regarding certification and lead -safe work practices beginning in April 2010.
• Ask your client to share the results of any previously conducted lead tests.
• Provide your client with references from at least three recent jobs involving homes built before 1978.
• Keep records to demonstrate that you and your workers have been trained in lead -safe work practices and that you followed leac
safe work practices on the job. To make recordkeeping easier, you may use the sample recordkeeping checklist that EPA hz
developed to help contractors comply with the renovation recordkeeping requirements.
• Read about how to mply with EPA's rule in the EPA Small Entity Compliance Guide to Renovate Right.
• Read abo�,, w to e lead -safe work practices in EPA's Steps to Lead Safe Renovation, Repair and Painting.
F YOU'R OT
EAD-SAFE CERTIFIED,
ISTURBING
JUST SIX
SQUARE FEET
COULD COST YOU
BIG TIM
Signature
,E. /3. ac`4, .
Printed Name
— /r -1/
Date
DORT.OF
NAIURAL
RESOURCE!
Permit Acknowledgement of
Asbestos /Environmental Notification to Georgia EPD for
Projects Involving Demolition, Wrecking, or Renovation
The undersigned hereby acknowledges that the issuance of this permit does not in any way grant
permission to the owner, owner's representative, or permit holder to proceed with demolition,
wrecking, or renovation of a structure prior to the filing of any required ten (10) day "Project
Notification for Asbestos Renovation Encapsulation or Demolition" form in accordance with
the Georgia Asbestos Rules. The Georgia Environmental Protection Division administers the
rules. In most cases, the rules require both the owner and the involved contractors to assure the
portion of the building involved in the project is thoroughly inspected by an Accredited Asbestos
Inspector for materials that contain asbestos; and the removal of the asbestos before renovation,
wrecking, or demolition begins almost without exemption. Georgia EPD requires a completed
demolition notification from be submitted 10 workings days in advance even if no asbestos is
present in the building. Further guidance for regulatory compliance and contact telephone
numbers are provided by the brochures entitled Asbestos & Renovation and Asbestos and
Demolition. Other environmental issues such as asbestos removal techniques, lead abatement,
ground contamination, or unusual site conditions may have EPD regulations that could affect the
project.
Undersigned
c1;43
Printed Name
Aibe-J,41 pc-RsT
Date
Office Use Only:
Project Address:
Permit Number:
QF/
I
���nGOrn�i
June 30, 2010
The following deficiencies have reached an unacceptable level on the projects in the City of Tybee
Island. While the deficiencies are not necessarily the fault of the Owner or his agent, they are their
responsibilities. The two areas of deficiencies are in the two most basic and common BMPs on local
projects. They are:
Co — Construction Exit
Shc — Sediment Barrier
Correct installation information can be found not only in the "Green Book" but in the Field Manual for
Erosion and Sediment Control in Georgia, Fourth Edition 2002, 4310 Lexington Road, P.O. Box 8024,
Athens, GA 30603, telephone 706.542.3065, www.gaswcc.org, Georgia Soil and Water Conservation
Commission; http: / /www.gaswcc.org /docs/
field_manual 4ed.pdf.
Problems with the Co is not limited to the installation, but to the material. Specifically, the job site
personnel are telling me the stone delivered is the 1.5 " -3.5" stone they requested. I have experienced on
my own projects suppliers not adhering to the specs they are given with the orders. While I regret this
situation, I will no longer be accepting any deviation from the State requirements. The stone will be a
representation of 1.5 " -3.5" stone or larger. Gradations that are obviously smaller will no longer be
tolerated. The smaller stone allows for a smoother surface with smaller voids, thereby reducing the
function of the construction exit.
Similarly, I am finding Type A sediment barriers installed where Type C is required and shown on the
permit drawings. I have attempted to work with the Owners through increased inspections, additional
backup BMPs, etc. This has evidently become common knowledge based on the installations I am
finding. Where two rows are called for they will be installed with a separation that allows for the first one
to fail (fall over) without impacting the second one. The complete assembly and installation must be
compliant; steel or wood posts, post spacing, Type C or A.
There has been no discharge into state waters due to previous occasional deficiencies. However, the
increased frequency has created unnecessary exposure to:
1) Sediment discharge into nearby waters of the State,
2) Increased maintenance efforts by the DPW on downstream lines.
3) Due to #2, higher cost to island taxpayers.
I will be adhering strictly to the manual on all BMPs and not just these two.
Downer Davis
City of Tybee Island Consulting Engineer
Signature of •w =r /Contrac or
Coo r` �� � .
$_X4tu�41'0.s.
0.1
ft
REQUIRED FOR:
Building Permits
Relocation Permits
Sign Permits
Demolition Permits
Land Clearing, Disturbance or Excavation Permits
Tree Removal Permits
Relocation Permits
Special Review Permits
Site Plan Approval
Subdivision of Land
Sketch Plan Approval
Preliminary Plan Approval
Final Plat Approval
Minor Subdivision Plat Approval
Major Subdivision Plat Approval
In addition to specific requirements for the above permits and approvals, applicants must
demonstrate that they are in compliance with the City of Tybee Island Storm Water Management
requirements as outlined in Chapter 5 -4, Code of Ordinances.
Section 5 -4 -9 Prohibition provides, in part, as follows:
(4.) It is unlawful for any person to cause or permit any storm water to flow from their
property onto the property of another person, unless such storm water naturally
flowed thereon prior to any development activity.
(5.) It is unlawful for any person to interrupt the flow of any storm water runoff from
adjacent property onto their property by any development activity.
As part of the City's approval process applicants must illustrate how these storm water
management prohibitions will be met, including a showing of how storm water naturally flowed
on the affected property (prior to any development activity), and what changes in storm water
flow have occurred or are expected to occur, as attachments to this form. The City's approval or
permit does not guarantee that the applicant's plans will result in meeting requirements. The final
product must actually meet the City Ordinance requirements.
Applicant name: • /1;�`
Project I.D.: I (, P A r M
Attachments approved by: Date:
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3TAT1 OF ®EODam
CHATHAM! COUNTY
MEDDlN LANE 20' 21W
PLAT Of LOT6 4 & S, bLOCk 1<o, FO2T C12EVEAJ
AIA20, kA/OVJN AS N0. 4 P L.MWOOD DRIVE,
f0I2M &IZL Y /0 FALMWOOD DOVE , TYBEE /. LA AID, GA.
Fon: DAR.RELL BREEDE,J bC e212,0 40A k.. 82FEWEk1
DAB APRIL lG, I 84-
3CALC: /" = 30
C.O.C. FIELD
� ! fl no rvpoi NT
ADJ. METHOD
O.C. PLAT
2010 Chatham County Board of Assessors
Property Record Card Page 1 of 1 Requested By: READONLY 6/28/2010
4 -0002 -19 -001
16 PALMWOOD ST TYBEE ISLAND
APPRAISER tlwhitfi LOTS 4 AND 5 BLOCK 16 FORT SCREV EN GAINES LISA H
LAST INSP 06/12/2007 WARD TYBEE ISLAND SAVANNA H BEACH 146 OYSTER HOUSE ROAD
APPR ZONE 000008 RICHMOND HILL, GA 31324 -6102
CAMA ASMT
304,800 304,800 LAND 2
42,300 42,300 BLDG 1
6,100 6,100 OBXF 6
353,200 353,200 Cost - MS
SALES BOOK I PAGE INS VI QU RSN PRICE
CODES
PROPERTY USE 0006 Residential
UTA 0004 Tybee Island
NBHD 020270.00 T270 Tybee Screven
EXEMPTIONS
1/25/1999 200K 0110 WD I Q 155,000
GRANTOR: WESTWAY HOLDING COPRORATI,
GRANTEE: GAINES LISA H.
1/25/1999 200K 0107 WD I U UR 155,000
GRANTOR: HARDING PETER 3 M & MERYT,
GRANTEE: WESTWAY HOLDING CORPORATI,
5/21/1997 185Q 0608 WD I Q 135,000
GRANTOR: SANDERS RALPH T & FRANCES,
GRANTEE: HARDING PETER,
PERMITS TYPE DATE AMOUNT
HISTORY
LAND IMPR TOTAL
48,400 353,200 Cama
91,500 396,500 Over
91,500 396,500 Over
396,500 NC
64,000 389,000 Cama
040055 RN 2/10/2004 Issued 200
2010 304,800
2009 305,000
2008 305,000
2007
2006 325,000
COMMENTS 11/17/2008 ADD CHG 7 -23-97 DH PER PO 97
11/17/2008 ADD CHG PER P/O 11/17/08 DLB
4/20/1998 ADD CHG 4 -20-98 DH PER OWNER
4/14/1998 'WAR/D 1850608 5-23 -97
NOTES
BUILDING SECTION CONSTRUCTION TYPE RCN AYB EYB DEP TYPE PHYS ECON
FUNC OBSV / % TOTAL DEP % RCNLD U.FACTOR MKT VAL
84369 -1 Residential 72,419 1970 1985 MS 27.00 0.00
0.00 0.00 27.00 52,866 42,300
24
12•
12' ■.n
�
12'
a,
a�w� �'
1s • ...rd.
24 . • w
Iwo Min Ano
MM
3S'
I.
woo
w
MB HAS NO PLUMBING FIXTURES AND IS USED AS A STUDIO PICKED UP FOR 2000,
'
24'
u2
12'
12
32'
I.
WAS NOT PREY. ON PRC .SEVERAL MISC BLDGS
SECTION TYPE 1 - Main
AREA 1,008
TYPE 1 - Single- family Residence
FRAME 1 - Stud Frame
STYLE 1 -One Story 100.00%
QUALITY 3.00
CONDITION 3.00
# UNITS 0
#OF BEDS /BATHS 3 / 2.00
COMPONENTS UNITS % QUAL
R1 108 Frame, Siding, Wood - 100.00
R2 208 Composition Shingle - 100.00
R3 352 Heat Pump - 100.00
R4 402 Automatic Floor Cover Allowanc - -
R6 601 Plumbing Fixtures ( #) 5.00 -
R6 602 Plumbing Rough -ins ( #) 1.00 -
R6 622 Raised Subfloor (% or SF) - 100.00
EXTRA FEA fURES
ID# BLDG # SYSTEM DESC DIM 1 DIM 2 UNITS QL UNIT PRICE
RCN AYB EYB DT ECON FUNC SP 5P% RCNLD MKT VALUE
136401 84369 WOOD DECK AV 8 38 304.00 A 7.98
136402 84369 WOOD DECK AV 8 8 64.00 A 16.47
136403 84369 MISC BUILD. AV 0 0 432.00 A 15.05
BLDG USED AS STUDIO
136404 84369 MISC BUILD. AV 12 16 192.00 L 15.05
136405 84369 MISC BUILD. AV 6 8 48.00 L 15.05
136406 84369 MISC BUILD. AV 4 4 16.00 L 15.05
2,426 1985 1985 2R 485 500
1,054 1985 1985 2R 211 200
6,502 1985 1985 IR 4,746 4,700
2,890 1985 1985 2R 578 600
722 1985 1985 2R 144 100
241 1985 1985 2R 48 0
LAND
ID# USE DESC FRONT DEPTH UNITS /TYPE PRICE ZONING
SIZE LCTN TOPO OTHER ADJ1 ADJ2 ADJ3 ADJ4 MKT VALUE
108448 SINGLE FAMILY RES 0 0 7,000.000 SF 42.00 R1
.38 AC
108449 SINGLE FAMILY RES 0 0 2,553.000 SF 42.00 R1
.38 AC
1.00 279,300
1.00 SZ -75 25,500
Subject Photo Page
Borrower/Cient Owner Lisa Gaines
Property Address 16 Palmwood Drive
City Tybee Island
County Chatham
State GA
Zip Code 31328
Lender Ezekial B. Gaines, III
Subject Front
16 Palmwood Drive
Sales Price N/A
Gross Living Area 1,023
Total Rooms 6
Total Bedrooms 3
Total Bathrooms 1
Location Tybee Island
Mew Sim Houses
Site 17,300 SF
Crafty Average
Age 1970
Subject Rear
Rec House
Form PICPIX.SR — 'TOTAL for Windows appraisal software by a la mode, inc. — 1-800-ALAMODE
t mac.,
*;1
_
I
ail insulatEolls rxius
comply with Tha Georgia
Mate Energy p Coda
_Edition
and ,State of Georgie
Amehdmsi tb
czt
ij
lG PA-km f,o,
7r,P V�`c.c,� (iY'J
ALL CONSTRUCTION MUST COMP! ..‘f WITH THE
SSTD 10 AND TNT' I+ =D Twp.
FAMILY DWELLING CODE ZaoG EDITION
AND STATE OF GEORGIA AMENDMENT
urc.
'An Approved Se} rims Must
ae,na',n on ...el) Site at All Timms"
1VIi-!DOW , DOORS AND SK; L'GNTS
SSTD 10.99 TABLES 602A1, 602A2, 60 A3, SECT. 6114
AND IRC 301.2,1,2
WINDOWS, GLASS DOORS AND SKYLIG TS SHALL BE
APPROVED AND INSTALLED TO COMP Y WITH BOTH
POSITIVE AND NEGATIVE PRESSURE ,
Fyi't4 -1 ..,
t
4 -- .9i2 --->
4c4-- 43'
>1
f =<<i PitMbInt Installations must
comply with The International Pluirrolt q
C. �,_ _ Edition and Stater
corgi >1 Amendmernt-.
Ali Electrical lnstalia'ions Must
comply with The National Electric
Co e_Z !Edition and Statir
of Georgia Ame,tL neat s
Joy. - "4010
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Pr-2, r � u r� 12-14 v 5 Un.
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ot.tdo+oru and r:;tsr. fitchen
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.ELI, CONSTRUCTION MUST COMPLY WITH; THi.
Sr T�l.4_ _ a ND THE TRO.O!N AND}TV O
_'�AM1.Y W L?. NG' CODE 2Gn
AND STATE OF GEORt'IA AMENDMENTS
. ROOF FRAMING .
�'� IRC SECT, 802 AND SSTD 10.05 SECT. 102- AND 30?
ALLOWED ROOF SLOPES PIE 2112 7112 FOR WOOD
'Af r 'I15`:::,;aw, 61. ALL HOI.ES IN HOLD DOWNS
TO BE FIL! 1 USING MANUFACTURER'S NAILS.
Sect. R- 311.5.6 HANDRAILS & R -312 GUARDRAIL
Stairs more than 30" in height require
34 "/38" handrails.
Porches, balconies, ramp & decks more
than 30" above grade require 36" guardrails.
Leer est o . enln ' permitted is 4"
H1
Itt
Plur„biri i:Matallat`:.,iS rni4st
comply with The inlernationai Pium air:c
4"_.7Q(• Edition and State
"[ ileowgio. Amendments
All ElGctrIcai Installations; max
comply with The Nationel Elechic
(ode ZaZ 2.7ditIon and State
al Georgia Amenfmant.
eTh
Date: — /2 — H
Name: T, 6. `4
Homeowner Affidavit
Telephone Number: 7 (� - 4`S i i( 2 (
Address of Project: / t9/11- t u„00/) l�2
To Whom It May Concern:
I do hereby certify that I am the owner of the above referenced dwelling and am requesting the right to perform the
work detailed on the attached application. This is a single - family dwelling and I am now (or will be, when the
construction is complete) residing at this location.
I understand it is a violation of State law for me to hire anyone to assist me in this task. I understand than any
violations of this agreement will be just cause for the permit to be voided and legal action may be taken against me which
could result in my loss of electrical service.
Signature of Owner:
(do not sign until in the presence of a Notary Public)
SUBSCRIBED TO AND SWORN BEFORE ME THIS 2- DAY OF � ,
NOTARY BLIC
My Commission Expires 0'7 105 12-0 It
JANICE G. ELLIOTT
Notary Public, Chatham County, GA
My Commission Expires July 5, 2011
P.O. Box 2749 — 403 Butler Avenue, Tybee Island, Georgia 31328 -2749
(912) 786 -4573 — FAX (912) 786 -9539
www.cityoftybee.org