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HomeMy Public PortalAboutLEWIS AV_134.pdfCITY OF TYBEE ISLAND BUILDING PERMIT WORK DESCRIPTION LIFT HOME OUT OF FLOOD ZONE WORK LOCATION 134 LEWIS AVE DATE ISSUED: 10-16-2020 PERMIT #: 200481 OWNER NAME ROGER BANISTER ADDRESS 134 LEWIS AVE CITY, ST, ZIP TYBEE ISLAND GA 31328 PHONE NUMBER CONTRACTOR NAME AAA GENERAL CONTRACTORS ADDRESS 478 JASMINE DR CITY STATE ZIP WINDER GA 30680 FLOOD ZONE BUILDING VALUATION SQUARE FOOTAGE OCCUPANCY TYPE TOTAL FEES CHARGED PROPERTY IDENTIFICATION # P $ 1,180.00 PROJECT VALUATION $141,795.42 TOTAL BALANCE DUE: $1,180.00 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, Georgia 912-472-5030 • Fax 912-786-9539 APPLICATION FOR BUILDING PERMIT Property Address: 13" li w.�5 rive phccms 's/ isj PIN: Owner Architect or Engineer Contractor Name Royer 48e'rji1 F'po..►u 5,sA 01 el< A RA Getvru 1 Cowl; Mailing Address Lew's1 m e -rot s 6.:, . 313,2t 8�7d'-cm SF, Sv at b -rove, I j�Nd�S £(.3-) . 13 7 Ne Lc.'C'1. f Rd Zc 10 7,5 ice} ;,ud e e #- 3o4 g - Telephone Home: !td-756-`7oIca► Cell: Office: Cell: 77040- 1339 339 Office: ?7e- �� •7-7 t 1 ! 1 Cell: -770-5do-co9e, Check alt that apply ..N Single Family ❑ Discovery/Tearout Duplex 0 Demolition or Relocation ❑ Footprint Changes /Q Other Aa:;Sr ,1.lt5 49 ❑ Multi -Family units ❑ additional square ❑ * Commercial unit(s) feet heated/cooled e 1,5 �' * A commercial project requires 2 sets of sealed drawings by a design professional and construction by a contractor with the appropriate State of Georgia professional license. A commercial project may require Site Plan Approval. Details of Project: /I A /I &clue v're.1 C o u f&ct is ,4 0-5 Lee -4) CoIG, t." [..-i e 1 5-. , s e f A e A i, tis P (veed-ed t:,._)- 1317, he co 5 f1 ✓e -fo a t' .' fu: A � F cD f cc_1" terLs4 ri111i'sCaNivec,L" 0I r4c-evo;piec'- 115eI`ViC(-S 4' C_6; ve Estimated Cost of Construction: $ /'4ij 7 5:I 'r T �i L td G p cuprJ ij (materials +labor + proftloverhead) /fl yf , e If applicable, attach a copy of the certified elevation certificate and/or survey of the property. Depending upon the scope of the work, two sets of construction drawings and/or a site plan may be required. Year Built: 19 5 5 Listed on National Historic Register or located within a National Historic District? Y /� • Buildings older than 50 years may be eligible to be listed on the State / National Register. With this designation, you may be eligible to take advantage of various tax incentive programs while preserving the heritage of Tybee Island. • Also see the Tybee Island Land Development Code Article 14: Historic Preservation During construction: On -site estroom facilities wil) be provided through 61 + �, i 50 l U t# oiu Construction debris will be disposed by Alla ild ti'L (A -S e by means of D0,4rps fees . I understand that I must comply with zoning. flood damage control, building, fire, shore protection and wetland ordinances, FEMA regulations and all applicable codes and regulations. I realize that I must ensure the adequacy of drainage of this property so that surrounding property is in no way adversely affected as required by Article 16, Stormwater Management. I accept responsibility for any corrective actions that may be necessary to restore drainage impaired by this permitted construction. . 11 Date: oO, 0 Signature: Tinted Name of Applicant: w ; j 1; 5 Di A& ke5 G Note: A permit normally takes 7 to 10 d ys to process. Processing time for a historic structure may be longer. Approvals: Planning & Zoning Manager Building Official Water/Sewer Storm/Drainage City Manager ature Date 1v -1Y2, FEES 5-i3•©6 Permit 70q. od Inspections `faCv•Cd Cap. Cost Rec.-- Water Tap — Sewer Stub --- Eng. Fees — Aid to Const. — TOTAL iigo.oO i15 CITY OF TYBEE ISLAND CERTIFICATE OF OCCUPANCY DATE COMPLETED: 6/28/2021 This Certificate issued pursuant to the requirements of the Standard Building Code Certifying that at the time of issuance this structure was in compliance with the various ordinances of the Jurisdiction regulating building construction or use. PERMIT #: 200481 PROPOSED USE: LIFT HOME OUT OF FLOOD ZONE OCCUPANCY TYPE: P CONTACT NAME ROGER BANISTER CONTACT ADDRESS 134 LEWIS AVE CONTACT CITY STATE ZIP TYBEE ISLAND GA 31328 PROPERTY ADDRESS 134 LEWIS AVE APPROVED BY: P. O. Box 2749 - 403 Butler Avenue, Tybee Island, Georgia 31328 (912) 786-4573 - FAX (912) 786-5737 www.cityoftybee.org NOTICE TO BERYL AND ROGER D. BANISTER: This is a legal document and you are advised to discuss the terms of this Agreement with an attorney prior to signing. HAZARD MITIGATION ASSISTANCE AGREEMENT THIS AGREEMENT ("Agreement") is made and entered into this day of February, 2020 by and between the City of Tybee Island, a municipal corporation of the State of Georgia ("City"), and Beryl Banister and Roger D. Banister] (individually and jointly, "Owner"), (collectively, "Parties"). WITNESSETH: WHEREAS, the City is a municipal corporation established under the Georgia Constitution and the Laws of Georgia, and is authorized to, among other things, accept and administer grants from state and federal authorities to enhance the quality of life in Tybee Island; and WHEREAS, the United States Congress, through an appropriation to the Federal Emergency Management Agency ("FEMA"), has made available to the Georgia Emergency Management and Homeland Security Agency ("GEMA"), Hazard Mitigation Grant Program ("HMGP") funds for hazard mitigation projects; and WHEREAS, the City, in conjunction with the Owner, has submitted an application to GEMA for HMGP funds and GEMA has approved the application for the property at 134 Lewis Ave., Tybee Island, GA 31328 ("Property"); and WHEREAS, the City Council has approved acceptance of a grant from GEMA in the amount of $1,548,318.00 ("Grant") and has authorized the Mayor to execute a Recipient- Subrecipient Hazard Mitigation Assistance Agreement ("Project Agreement") with GEMA to effectuate distribution of the Grant funds to the Owner, said Project Agreement being attached hereto as Exhibit "A" (with Owner's Acknowledgement of Conditions For Mitigation of Property in a Special Flood Hazard Area With FEMA Grant Funds being the sole Exhibit "C" thereto as other owners' Acknowledgements having been redacted along with cost information for other properties); and WHEREAS, of the Grant, $104,544.00 has been budgeted as the Total Cost for hazard mitigation of Owner's Property as per the signed Homeowner Acknowledgement of Cost Estimate and Structure Elevation Project Local Match ("Acknowledgement of Cost Estimate") attached hereto as Exhibit "B"; and WHEREAS, the Owner represents that Owner will hire contractors who possess the requisite skills, knowledge, qualifications, and experience to provide or cause to be performed the services identified herein; and Page 1 of 9 WHEREAS, the Owner further represents that Owner will perform the duties and obligations as set out in the Project Agreement and this Agreement; and WHEREAS, the Owner is aware of the contents of the Project Agreement between the City and GEMA, and other conditions and requirements of FEMA and GEMA concerning the Grant. NOW THEREFORE, the Parties, in reliance upon the foregoing recitals and in consideration of the mutual promises and covenants contained herein, agree as follows: 1. RECITALS. The statements contained in the recitation of facts set forth above are true and correct and are hereby incorporated into and made a part of this Agreement. 2. PURPOSE. The purpose of this Agreement shall be to set forth the duties of the City and the Owner in regard to the Hazard Mitigation Assistance Project ("Project") described in the Project Agreement, which is attached hereto as Exhibit "A" and made a part hereof by reference. 3. CITY'S DUTIES. A. The City's duties under this Agreement are limited to assisting the Owner in making an application for matching fund reimbursements in accordance with the Project Agreement, and, if necessary, disbursing funds received as reimbursements to the Owner. B. The City shall process the Owner's requests for reimbursement from the Grant in accordance with the Project Agreement. The City shall have no liability to the Owner for reimbursement claims that are rejected by GEMA for any reason, nor shall the City be liable for any failure of the Owner to receive the maximum amount reimbursable under the Project Agreement. 4. RIGHT TO ENTER AND INSPECT. The City shall have the right to visit any site used by the Owner for any part of the Project funded under this Agreement, at any reasonable time, for the purpose of making inspections including a review or analysis of the financial or service records of the Owner pertaining to this Agreement. 5. THE OWNER'S DUTIES. The Owner shall: A. Purchase all goods and services necessary to carry out their responsibilities hereunder by March 31, 2021, in accordance with the Project Agreement (Exhibit "A") and in accordance with the Acknowledgement of Cost Estimate (Exhibit "B") (both Exhibits "A" and "B" incorporated herein by reference). Page 2 of 9 Agreement. B. Provide the City with sufficient documentation in accordance with the rules of GEMA and/or FEMA to enable the City to reimburse the Owner for those costs and expenses authorized by the Project Agreement. Owner recognizes that after reimbursing the Owner for these costs and expenses, the City will seek reimbursement from GEMA and/or FEMA and to the extent the City is not reimbursed these costs and expenses by GEMA or FEMA the Owner shall be liable to the City for those unreimbursed costs and expenses. C. Use Grant funds in accordance with the Project Agreement and assume and perform all of the duties and responsibilities for which the City may be obligated under the Project Agreement, except as otherwise specified herein. If the Owner uses any funds provided from the Grant for any purpose other than authorized under this Agreement or the Project Agreement, the Owner shall repay such funds to the City or GEMA. OWNER ACKNOWLEDGES THAT UPON COMPLETION OF CONSTRUCTION THAT THE FIRST FLOOR ELEVATION MUST BE A MINIMUM OF TWO FEET ABOVE BASE FLOOD ELEVATION, NOTWITHSTANDING ANYTHING TO THE CONTRARY IN ANY DOCUMENT PERTAINING TO THE GRANT. D. Provide such other funding as may be necessary to complete the Owner's duties and responsibilities under this Agreement, which may include the payment of 100% of the amount that the actual Total Cost exceeds the Total Cost stated in Exhibit "B". E. Be responsible for the administration of all contracts, funded by the Grant or otherwise, entered into by and between the Owner and any persons or entities for the acquisition of materials or the performance of services in connection with the Project, regardless of whether a contract qualifies for reimbursement from the Grant. The Owner shall establish and maintain records to document all costs incurred by them in connection with the Project. All contracts funded by the Grant shall be provided to the City or their designee for record keeping prior to and following execution. F. The Owner shall be liable for repayment of any funds demanded by GEMA notwithstanding whether the demand is made to the City or directly to the Owner. G. Cooperate with the City to achieve the goals and objectives set out in this H. Sign and execute any documents in a recordable form to create any restrictions on the Property that may be required by FEMA, GEMA or the City pursuant to the Project Agreement, the Grant or this Agreement. 6. TERM. The term of this Agreement ("Term") shall commence upon the execution of this Agreement by the Parties and shall expire on March 31, 2021. Page 3of9 7. INSURANCE. The Owner shall have a Home Owner Insurance policy, acceptable to the City, in its sole discretion, providing inter alia, for replacement cost of the structure. Proof of insurance for all policies shall be provided to and approved by the City prior to the start of construction. For structures that remain in the Special Flood Hazard Area (SFHA) after the implementation of the mitigation project, flood insurance must be maintained for the life of the structure to an amount at least equal to the project cost or to the maximum limit of coverage made available with respect to the particular property, whichever is less. The maximum limit of coverage made available is defined as the replacement cost value of the structure up to $250,000 for residential and $500,000 for nonresidential. Hazard coverage on the Property for full replacement cost value of any and all structures must be maintained during the life of the Property or life of the structures regardless of transfer of ownership of such property. 8. THE OWNER'S WAIVER, INDEMNIFICATION AND RELEASE. A. Waiver and Release. Owner acknowledges that City's duties to Owner in regard to the Grant and under this Agreement are strictly limited to those duties specifically set forth in Paragraph 3 above and Owner hereby waives any claim against the City and releases, discharges and covenants not to sue the City and its past, current, and future officers and elected officials, employees, agents, representatives, attorneys, and any related or affiliated persons and entities for any claim whatsoever, whether known or unknown, whether arising before or after the date of this Agreement, whether in tort or contract, whether based upon federal, state, or local law, whether in law or equity, or of any other type, which in any way is related to or arises from the City's role as the Subrecipient of the Grant and/or arises from or is related to the City performing, attempting to perform, or failing to perform the duties set forth in Paragraph 3 above or anywhere else in this Agreement. Further, no other duties shall be created by any action of the City, except for a written amendment to this Agreement. B. Indemnification. The Owner shall defend, indemnify, pay on behalf of and hold harmless the City and its officers, employees, agents, and servants, whether they be current or former (collectively, "Indemnified Parties"), from and against any and all actions, claims, liabilities, losses, costs and expenses, in law or in equity, including but not limited to attorneys' fees at trial and appellate levels, reasonable investigative and discovery costs, court costs or claims (collectively, "Claims") for: 1. Bodily injury or death of persons and for loss of or damage to property, of every kind and nature whatsoever, which in any manner directly or indirectly may arise or be alleged to have arisen, or resulted or alleged to have resulted from the negligent acts or omissions or other wrongful conduct of the Owner, their employees, contractors, and agents in connection with the Owner's performance pursuant to this Agreement. 2. Failure to perform all the duties and responsibilities for which the City may be obligated under the Project Agreement, this Agreement, Construction Agreements, Page 4 of 9 as hereinafter defined or any other contracts executed by the Owner which are related to the Project. under this Agreement. 3. Claims arising out of or connected with the Owner's performance C. Reimbursement of City. As per Paragraph 5.A. above, Owner shall reimburse the City for any reimbursement payment that the City makes to Owner to the extent that the City is not reimbursed by GEMA and/or FEMA. D. This Paragraph 8 shall survive expiration or termination of this Agreement. 9. TIME AND ACKNOWLEDGEMENTS. Owner acknowledges that Owner has read this Agreement, that Owner has been provided a period of ten days (10) days from the time Owner received this Agreement to consider its terms and to consider whether to sign it and that Owner has been also advised in writing to discuss its terms with an attorney or other advisor. If this Agreement is signed before the end of the ten (10) day period, Owner acknowledges that it is because Owner freely chose to do so after carefully considering the terms of this Agreement and after having had an opportunity to consult with anyone Owner wished, including an attorney. 10. CONSTRUCTION AGREEMENTS. A. Parties to Construction Agreements. All Construction Agreements ("Construction Agreements") shall be entered into between the Owner and the contractor B. Negotiation and Terms and Conditions. The Owner shall be responsible for negotiating the terms and conditions of all Construction Agreements, provided that the Owner shall ensure that all Construction Agreements require the contractor to (i) name the Indemnified Parties as additional insureds on all insurance required to be obtained by the contractor pursuant to the Construction Agreement, and (ii) defend and indemnify the Indemnified Parties against any and all Claims related to the contractor's services provided to the Owner. C. Project Agreement. The Project Agreement shall be specifically referenced in and incorporated by reference into all Construction Agreements and attached as an exhibit to all Construction Agreements. 11. BOOKS AND RECORDS. Owner shall keep accurate and sufficient books, records, and documentation related to this Agreement and the Project Agreement (e.g. contracts and correspondence between the Owner and City and contracts and correspondence between the Owner and third parties) at the address for delivery of notices set forth in this Agreement. Books, records and documentation shall contain all financial and work -related details associated with any project expenditures or activities. All such books, records, and documentation shall be kept by the Owner and shall be open to examination, audit and copying by the City during the Page 5 of 9 Term and for a period of five (5) years following termination or expiration of this Agreement. Owner shall bear the costs associated with the retention of books, records and documentation. Nothing herein shall be construed to allow destruction of records that may be required to be retained longer by the Official Code of Georgia. 12. NO THIRD PARTY BENEFICIARIES. This Agreement shall inure to the benefit of the Parties and is for the exclusive benefit of the Parties. This Agreement shall not be deemed to be made for the benefit of any other entity or person not so specified. 13. COMPLIANCE WITH FEDERAL. STATE, COUNTY, AND LOCAL LAWS. Owner shall comply with all applicable federal, state, and local laws, ordinances, rules and regulations, the federal and state constitutions, and orders and decrees of any lawful authorities having jurisdiction over the matter at issue (collectively. "Laws"). 14. APPLICABLE LAW/VENUE. This Agreement shall be governed by and interpreted in accordance with the laws of the State of Georgia. Venue for state court actions shall be in Chatham County, Georgia. Venue for federal court actions shall be in the United States District Court for the Southern District of Georgia, Savannah Division. Each party waives any defense of improper or inconvenient venue as to either court and consents to personal jurisdiction in either court. 15. AMENDMENTS. This Agreement may be altered, amended, modified or revised only by a written instrument executed by the Parties. 16. ENTIRE AGREEMENT. This Agreement constitutes the complete, full and wholly independent agreement among the parties to this Agreement with regard to the matters contained herein. This Agreement also supersedes all prior representations, statements and understandings among the parties to this Agreement with respect to the matters and things addressed herein, either written or oral. 17. SEVERABILITY. Should any section or part of any section of this Agreement be rendered void, invalid, or unenforceable by any court of law, for any reason, such a determination shall not render void, invalid, or unenforceable any other section or any part of any section of this contract. 18. NOTIFICATION. A. All notices, requests, demands, or other communications hereunder shall be in writing and shall be deemed to have been served as of the delivery date appearing upon the return receipt if sent by certified mail, postage prepaid with return receipt requested, at the address listed below, or upon the actual date of delivery, if hand delivered to the address below. Either party may change the below -listed address at which it receives written notices by so notifying the other party hereto in writing. Page 6 of 9 Owner: Beryl and Roger D. Banister 134 Lewis Ave. Tybee Island, GA 31328 City: George Shaw Planning & Zoning Manager P.O. Box 2749 403 Butler Ave Tybee Island, GA 31328 With a copy to: Edward M. Hughes City Attorney P.O. Box 9946 Savannah, GA 31412 B. Each party shall give the other party prompt notice of any claim coming to its knowledge that directly or indirectly affects the other party. 19. WAIVER. No act of omission or commission of either party, including without limitation, any failure to exercise any right, remedy, or recourse, shall be deemed to be a waiver, release, or modification of the same. Such a waiver, release. or modification is to be effected only through a written modification to this Agreement. 20. FUNDING. The sole source of City funding for this Agreement, including, but not limited to the obligations set forth in paragraph 3 of this Agreement, shall be from the Grant. The City is under no obligation to provide funds from any other source. In the event that the Grant is reduced or withheld by FEMA or GEMA, then the City shall not be liable for payment of funds from any City fund other than the Grant. 21. HEADINGS. The paragraph headings are inserted herein for convenience and reference only, and in no way define, limit, or otherwise describe the scope or intent of any provisions hereof. 22. COUNTERPARTS. This Agreement may be executed in one or more counterparts, each of which may be executed by less than all of the parties to this Agreement but all of which shall be construed together as a single instrument. 23. ASSIGNMENT. This Agreement may not be assigned by the Owner without the prior written consent of the City, which consent may be granted or denied in its sole discretion. 24. CONTRACTING. The parties contemplate that the Owner may contract with third parties to carry out their duties and responsibilities under this Agreement. Such contracting shall be permitted, provided that the Owner shall at all times remain liable for performing their duties and responsibilities under this Agreement. Page 7 of 9 EXHIBIT "B" Homeowner Acknowledgement of Cost Estimate and Structure Elevation Project Local Match [Post -Award] Owner Name: A- ko ,�"'/j. .66Property Address: 134 Lewis Ave., Tybee island, GA 31328 Phone Number: 912-786-7012 Email Address: rgrbnstr@yahoo.com, tybeearbee@hotmail.com You have indicated intent to voluntarily participate in the Federal Emergency Management Agency's (FEMA) Hazard Mitigation Grant Program (HMGP) for DR -4338 Hurricane Irma, administered through the Georgia Emergency Management Agency and the City of Tybee Island as the grant subrecipient. HMGP is a cost reimbursement program and requires a cost sharing commitment from participants. This signed acknowledgement is intended to inform homeowners of the approved project cost for their property and their estimated financial responsibility if the grant is awarded. The amounts provided below are estimates. Exact financial responsibility will be calculated based upon actual project costs. Per HMGP program guidance, FEMA may contribute up to 75 percent cost share for eligible project costs. In addition, due to Chatham County's designation as a Declared County under the Major Disaster Declaration for DR -4338, the State of Georgia will contribute up to 10 percent of the total project cost share. Homeowners are responsible for the remaining 15 percent share of eligible project costs. The total cost estimate for the structure elevation project proposed at the above property address is provided below. Structure Eicvation Cost Estimate Engineering & Permitting Local (Homeowner) Share Amount (IS%) $7,74.4.00 $96,800.00 $104,544.00 $75,682.00 Construction Total Project Cost Note that the project costs above include engineering/design, permitting, and construction costs only; homeowners will not be responsible for the pre -award and project management/grants administration fees incurred by the City, included under Exhibit UJ" of the Recipient-Subrecipient Agreement. The original cost estimate to mitigate your property was calculated using local construction market knowledge in conjunction with field -collected structure data. Per applicable guidance, FEMA will accept cost estimates established using nationally published or local cost estimating guides to support the project cost estimate and determination of cost effectiveness. It is important to reiterate that the HMGP program is a cost -reimbursement program and actual eligible costs incurred by the participating homeowner will be reimbursed following the submittal of necessary supporting documentation. Furthermore, the total Federal and State share amounts shown above demonstrate the total amount available for reimbursement to the homeowner. Rev. 01/2020 8y signing this form, I affirm and understand the following: • 1 have been notified and understand the total cost estimate of my structure elevation project. • Participation in the application process and grant program is voluntary. • A focal engineering firm produced the cost estimate and scope of work for my structure elevation project for the purpose of application development and at no cost to me. • Any variation in the awarded budget and scope of work must be coordinated with the City or designee for approval prior to commencing any project work. • I am required to pay the local match (15%) to mitigate my home and I have the resources to meet such requirements. • I understand that the program is cost reimbursable and that I may be reimbursed at 85 percent of the actual eligible costs of the project. Reimbursement will occur as requests, using prescribed forms with all appropriate and required source documentation, are submitted to City of Tybee Island. i&L.4„z, peg D. 6x/mAIAm-------- Homeowner Signature Community Official Signatu Date Homeowner Signature Date A.d i`re r - Title 25. CITY CONSENT AND ACTION: A. City Approval. For the purposes of this Agreement, any required written permission, consent, approval or agreement ("Approval") by the City means the administrative Approval of the Mayor or her Designee unless otherwise set forth herein and such Approval shall be in addition to any and all permits and other licenses required by law or this Agreement. B. City Action. For the purposes of this Agreement any right of the City to take any action permitted, allowed or required by this Agreement, may be exercised by the Mayor or his Designee, unless otherwise set forth herein. IN WITNESS WHEREOF, the Parties have caused this Agreement to be executed on the date first above written. OWNER(S): Sign: Print: Sign: (c:?M, L A WITNESSE : Sign: t 4 _Print: („j� Il a Sign: Print: G - Print: CC(1 STATE OF GEORGIA ) COUNTY OF CHATHAM ) The foregoing instrument was acknowledged before me this '/ day of ac is,b by Be rg ( 4-- Ro.5 u 13c..r ; s Ii r- who is/are personally known to me, or who has/have produced me.: . as identification, and who appeared before me at the time of notarization. (SEAL) SIGN: Page 8 of 9 Notary Public Lisa F Lanier NOTARY PUBLIC Chatham County, GEORGIA My Comm. Expires 09/25/2021 CITY OF TYBEE ISLAND, GEORGIA: By: Shirley Sessions, Rayor ATTEST: J n LeViner, Clerk of Council STATE OF GEORGIA ) COUNTY OF CHATHAM ) The foregoing instrument was acknowledged before me this day of by who is/are y personal) known to me, or who has/have produced as identification, and who appeared before me at the time of notarization. (SEAL) (SEAL) SIGN: APPROVED AS TO CONTENT: Edward M. Hughes, City tt Page 9 of 9 Notary Public Probate Court Return Mailing Address: PROBATE COURT OF CHATHAM COUNTY P.a. BOX 834` SAVANNAH, GA 1111115 OM ll lM 111E111 Doc ID 034114190004 Type: ORD Recorded: 10/11/2022 at 12:02:10 PM Fee Amt: $25.00 Page 1 of 4 Chatham, Ga. Clerk Superior Court Tammie Mosley Clerk Superior Court BK2934 PG5 17-520 Ili 11 111 Type: ORD • Kind: COURT ORDER Recorded: 9/8/2022 12:36:00 PM Fee Amt $25.00 Page 1 of 3 Chatham, Ga. Clerk Superior Court Tammie Mosley Clerk Superior Court Participant 1D(s): 3639644106, 0848497841 BK 2908 PG 181 -183 (Above space to be useajorjuurg rn oupenor L,oun utenc s office ofDeeds and Records) IN THE PROBATE COURT 01? CHATJIAM STATE OF GEORGIA IN RE: ROGER DALE BANISTER DECEASED COUNTY ) ) ESTATE NO. P11- 01n a. i)3 ) CERTIFICATE OF ORDER OF YEAR'S SUPPORT (Pursuant to O.C.G.A. § 53-3-11) DATE ORDER GRANTED: S b Gr L b „ GRANTOR: INAME OF DECE'DE`NT) ROGER DALE BANISTER GRANTEE: jFULL NAME OF EACH PERSON AWARDED YEAR'S SUPPORT. The Surviving Spouse and/or minor child(ren)] BERYL BANES fk'R ADDRESS OF GRAN'thE: 134 LEWIS AVENUE, TYBEEISLAND, GEORGIA 31328/P.O. BOX 1082, TYBEE ISLAND, GEORGIA 31328 CERTIFIED COPY This documant is a certified copy of the original document piked on record in the Clerk of Probate Court, Chatham County, GA. Given under my hand and seal this t t day of Dc_ ' 20 zz. opcspgputy Clerk, Probate Court of Chatham CaurlliPl E$ July 2017 Legal Description of Real Property and Interest Therein: All that certain lot, tract or parcel of laud situate, lying and being in the Town. of Tybee Island, County of Catham, State of Georgia and being known and designated upon that certain map or plan of Plam Terrace Subdivision, Camp Hammock, Ward 1, prepared by S.P. Kehoe, Jr., dated 'February 23, 1954 and recorded in the Office of the Clerkof the Superior Court of Chatham .County, Georgia in Plat Record Book "F", Folio 173, as Lot Number Fifty (55); said lot _ having frontage of 60 feet on a curve on the Southeast side of Lewis Avenue, being irregular in •shape and being bounded as follows: On the Northeast by Lot Number 56, said Subdivision, • Hammock and Ward; on the Southeast by Marsh; and on the Northwest by Lewis Avenue. ,SUBJECT, HOWEVER, to any lawful claims by the State of Georgia or other governmental body to such portions of said property as may be "Imarshland" as defined be the Coastal •Marsltla.nd Protection Act of 1970 and all valid restrictions, easements or rights -of -way of record. .2006 Kia Spectra Vin: KNAFE121X65210878 2011 Chevrolet Silveredo C150 Vin: IGCRCSE0XBZ150165 Original Certificate delivered or mailed to Clerk of Superior Court of County on , 2021 GPCSF 10 (I0j Ef£ 7n1y 2017 SIGNATT B OF ATTORNEY By: Certificate,Prepared by: stateBar# 732277 I do her- certify that the above information is based on the Order of the Probate Court issued on th- da = set out above and bat the above -information is true and correct. PROBATE COURT OF CHATHAM COUNTY lerk of the Proba Court P.O. BOX 8344 SAVANNAH, GA 31412 Probate Court Return Mailing Address • OPCSP 10 (I1] Eff. July 2017 oaerbey./„,,, 16 An .Pkiter tAttKr-- H&IGP 4294-0004 City of Tybee Island f+'.shi it 9" RECORDED DEED RESTRICTION AMENDMENT The subrecipient (or property owner) must legally record a notice that includes the name of the current property owner (including booklpage reference to record of the current title, if readily available), a legal description of the property, and the following notice of flood insurance requirements: This property has received Federal hazard mitigation assistance. Federal law requires that flood insurance coverage on this property must be maintained during the life of the property regardless of transfer of ownership of such property. Pursuant to 42 U.S.C. 5154a, notwithstanding any other provision of law, no Federal disaster relief assistance made available in a flood disaster area may be used to made a payment (including any loan assistance payment) to a person for repair, replacement, or restoration for damage to any personal, residential, or commercial property if that person at any time has received flood disaster assistance that was conditional on the person first having obtained flood insurance under applicable Federal law and subsequently having failed to obtain and maintain flood insurance as required under applicable Federal law an such property. The property owner is also required to maintain this property in accordance with the floodplsin management criteria of 44 CFR Section 603 and any city/county ordinance. RSA -4294, Property Elevation -19- Exhibit "I" CERTIFICATE OF OCCUPANCY REQUIREMENTS Permit # Job Address Job Name As Applicable r2O--a,/8! 13 Lf L-e_c,o'is Ave-. cw\t — A-141 a-0,ex- Qwne Contractor Post house number (and unit numbers if applicable) NA— Energy Code Compliance Certificate Pass Final Building inspections Elevation Certificate, Finished Construction As -built Survey Height Certification (can be noted on the as -built survey) N {� 770-S&o-CZ'qs Drainage Certification from Project Engineer Recorded Nonconversion Agreement (attached) must be recorded with Chatham County Breakaway Wall Certificate (V -Zone only) / V , Mitigation of Trees Payment of outstanding fees City of Tybee Island City staff will coordinate these items when the needed documents from the list above have been submitted. Please do not contact the engineer or director. N4 Drainage Certification from the City's Consulting Engineer Drainage Certification from the Director of Public Works Department FEMA Inspection from Planning & Zoning Manager ItlI1111tlYY!1If M911Milt Doc ID: 033151260001 Type: AGRE Recorded: 06/10/2021 at 01:37:08 PM Fee Amt: $25.00 Page 1 of 1 Chatham, Ga. Clerk Superior Court Tammie Mosley Clerk Superior Court BK 2 4 05 PG7 6 III 111 Cross reference to Book 397T? Page g15 — CITY OF TYBEE ISLAND COMMUNITY DEVELOPMENT NON -CONVERSION AGREEMENT FOR CERTAIN STRUCTURES IN THE FLOODPLAIN Application has been made for a permit from the City of Tybee Island, Georgia. Petuut # c2,0' D P? Property Owner: '�o9er �' e 1^4 1 l `'w't s� Address: 134. Lecosts Ave PIN: 4000 (4-OO Legal: Ley} 55 Palm Terrace 5U13 Saucsnrall Bea N. Z•tbes Ss( Base Flood Elevation at the site is 9 feet (NGVD) In accordance with the Flood Damage Prevention Ordinance of the City of Tybee Island, Georgia, the Property Owner agrees to the following: 1. That the enclosed area below the Base Flood Elevation shall be used solely for parking of vehicles, limited storage, or access to the building, and will never be used for human habitation without first becoming fully compliant with the Flood Damage Prevention Ordinance in effect at the time of conversion. 2. That all interior walls, ceilings, and floors below the Base Flood Elevation shall be unfinished or constructed of flood -resistant materials. 3. That mechanical, electrical, or plumbing devices shall not be installed below the Base Flood Elevation. 4. That the walls of the enclosed area below the Base Flood Elevation shall be equipped with at least two vents which permit the automatic entry and exit of floodwater with total openings of at least one square inch for every square foot of enclosed area below flood level. The vents shall be on at least two different walls, and the bottoms of the vents shall be no more than one foot above grade. If located in a V -zone, breakaway walls are required. 5. That the requested structure may be subject to increased premium rates for flood insurance available from the National Flood Insurance Program due to its location in a Special Flood Hazard Area. 6. That any variation in construction beyond what is permitted shall constitute a violation and be abatable as such. STATE OF GEORGIA COUNTY OF CHATHAM ature of Property Owner Subscribed to and sworn before me this OJ J Notary Public My commission expires: q Signature of Property Owner day of J w/1 , 20 c. isa F Lanier NOTARY PUBLIC pp��Chatham County, GEORGIA Note: A _Nonconverstil/d giCo last Ei l 251 cfructure or portion of a structure is built or substantially improved within the l00 ,year Floodplain below the Base Flood Elevation. A Nonconversion Agreement must satisfy all of the above conditions and requires proper recordation in the land records of Chatham County, Georgia. Witnes .'ignature Lec Cc_V` kct yzt L , C avx_ Lisa Schaaf s From: willla@windstream.net Sent: Friday, May 28, 2021 11:47 AM To: Lisa Schaaf Subject: Re: 134 LEWIS AVE Dear Lisa can you please email me the closing papers for 134 Lewis Ave. Bannister home thanks Willis, have done the Certificate of Elevation and have requested Mrs. Bannister to go to the court house to sign the affidavit not sure what else we need except for the Certificate of occupancy. Half the sheet rock was left in the house and no windows were changed out. Willis Original Message From: Lisa Schaaf <lschaaf@cityoftybee.org> To: willla@windstream.net Sent: Fri, 16 Oct 2020 14:09:57 -0400 (EDT) Subject: 134 LEWIS AVE @font -face {font -family: Centu ry; panose-1:2 4 6 4 5 5 5 2 3 4;} @font -face {font-family:"Cambria Math"; panose-1:2 4 5 3 5 4 6 3 2 4;} @font -face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001 pt; font-size:11.0pt; font-family:"Calibri",sans-serif;} a:link, span.MsoHyperlink {mso-style-priority:99; color:#0563C1; text -decoration: underline;} a:visited, span.MsoHyperlinkFollowed {mso-style-priority:99; color:#954F72; text-decoration:underline;} span.EmailStyle17 {mso-style-type: persona I -compose; font-family:"Calibri",sans-serif; color:windowtext;} .MsoChpDefault {mso-style-type:export-only; 1 City of Tybee 403 Butler Ave. Phone Permit No. Owner's Name Gen. Contractor Contact Information Island • Community Development Dept. Inspection Report • P.O.Box 2749 • Tybee Island, GA 31328 912.472.5033 • Fax 912.786.9539 *mot :mom* INTERNATIONAL CODE COUNCIL MEMBER Date Requested Date Needed Subcontractor Project Address Scope of Work Inspector Date of Inspection Inspection Inspection Inspection Pass :0 Fail ❑ Fee Inspection Pass Fail ^ Fee Pass ,'°E Fail I__! Fee Pass r1 Fail ❑ Fee City of Tybee 403 Butler Ave. Phone Permit No. Owner's Name Gen. Contractor Contact Information Island • Community Development Dept. Inspection Report • P.O.Box 2749 • Tybee Island, GA 31328 912.472.5033 • Fax 912.786.9539 :ull` _,rasa TIE 13 NAT 10MAL CODE COUNCIL MEMBER Date Requested Date Needed Subcontractor Project Address Scope of Work Inspector Date of Inspection Inspection Inspection Iease Inspection Inspection Pass'0 Fail Fee Pass Fail ❑ Fee Pass Fail l —f Fee Pass Fail Fee Permit No. City of Tybee Island • Community Development Dept. Inspection Report 403 Butler Ave. • P.O. Box 2749 • Tybee Island, GA 31328 Phone 912.472-5032 • Fax 912.786.9539 Owner's Name Gen. Contractor Contact Information Project Address Scope of Work Inspector MOM Milling= a INTERNATIONAL CODE COUNCIL MEMBER Date Requested Date Needed Subcontractor Date of Inspection Inspection Pass El Fail Fee Inspection Pass ❑ Fail ❑ Fee Inspection Pass ® Fail ❑ Fee Inspection Pass ❑ Fail ❑ Fee Owner's Name Gen. Contractor Contact Information City of Tybee Island • Community Development Dept. Inspection Report 403 Butler Ave. • P.O.Box 2749 • Tybee Island, GA 31328 Phone 912.472.5033 • Fax 912.786.9539 semi INTERNATIONAL CODE COUNCIL MEMBER Permit No. Date Requested Date Needed Subcontractor Project Address Scope of Work Inspector Date of Inspe Inspection P. ss • , ail 1 1 Fee Inspection Pass Fail ❑ Fee Inspection Pass ❑ Fail ❑ Fee Inspection Pass Fail ❑ Fee Enter Approval Details https://wiringapproval.southerncompany.com/CreateApproval.a Site Map I Home Contact Us W/A Approval Portal Home My Approvals Add Approval Search Manage Defaults User Profile Customer Service FAQs Contact Us Learn More GeorgiaPower.com Welcome lisaroseschaaf 0 Inspection Agency Information: TYBEE ISLAND Enter Approval Details User ID: lisaroseschaaf Help I Log Out Approval Information Inspector's Notes Inspection Agency ` Select One Inspector Select One Date '11/16/2020 1:07:35 PM Permit/Approval # Premise Id Type ' Select Type Classification * Select One Electrician Electrician Phone# Wiring Approval Submitted Service Order Status Address Contact Name Contact Phone # Street # Unit/Suite/Lot# Street Name Select One Also Known As Zip • Select City Select State Select Date Save & Copy Save Only Print Wiring Approval Type Address Number 134 Lewis Ave. 11/16/2020 200481 T -Pole Tybee Island, GA 31328 Submllt ©2011 Southern Company. All rights reserved. Privacy statement Terms of use Inspector's Note Edit 1 of 1 11/16/2020, 1:071 LEAD -BASED PAINT RRP RULES Ordinary renovation and maintenance activities can create dust that contains lead. Contractors who perform renovation, repairs, and painting jobs in pre -1978 housing and child -occupied facilities must, before beginning work, provide owners, tenants, and 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. After April 22, 2010, federal law will require you to be certified and to use lead -safe work practices. Georgia Environmental Protection Division Lead -Based Paint and Asbestos Program (404) 363-7026. Projects must be done by a Certified Lead Renovation Firm AND a Certified Renovator When disturbing lead-basedpainted or coated surfaces or components more than 6 ft2 per interior room or 20 ft2 of exterior surfaces AND all window replacements and partial demolitions of any size. ********************* 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. * * * * * * * * * * * * * * * * * * * * * BMPs While BMP deficiencies are not necessarily the fault of the owner or his agent, BMPs are their responsibility. Two areas of deficiencies are in the most basic and common BMPs; Co — Construction Exit and Sd1 — Sediment Barrier. Correct installation information can be found in the Field Manual for Erosion and Sediment Control in Georgia, Fourth Edition 2002, Georgia Soil and Water Conservation Commission; http://www.gaswcc.org/does/field_manual_4ed.pdf. Problems with the Co is not limited to the installation, but to material. The stone will be a representation of 1.5"-3.5" stone or larger. Type A sediment barriers have been installed where Type C is required and shown on the permit drawings. 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 Xi? 1 Signature for receipt of Lead Paint, Asbestos, and BMP notices Date U3111(:5 C7, J -..L& i o5` .e Printed Name p scale 1/8" rw. saw 01 . ,... 4I 2 2414',41 .t ��14g1� z 9/ +"s pia • 9M -M - MMgnMMM t t r 0,ttik 54 I � [te1 � p` a $ `fro re\ ro iv're• ' zI Y 7 12 10 • 4iI • +$ 5 /r/ eS ti I\Jo-1'e L-5:105ffi v..3 steksCIPA17 w CSe Rhi Ra t Q� He s .e ► ?`? I z 1 Ad 1Z X .5 7 4 ,rt r 12 24 38 LQr55 t131-1Le&t S f3ie Chatham County, Georgia https://www.chathamtax.org/PT/Datalets/PrintDatalet.aspx?pin PARID: 40004 14009 BANISTER BERYL ETAL* 134 LEWIS AVE Most Current Owner Current Owner Co -Owner Care Of Mailing Address BANISTER BERYL ETAL* PO BOX 1082 TYBEE ISLAND GA 31328 Digest Owner (January 1) Owner Co -Owner Address 1 Address 2 City State Zip BANISTER BERYL ETAL* PO BOX 1082 TYBEE ISLAND GA 31328 Parcel Status ACTIVE Parcel ID 40004 14009 Category Code RES - Residential Bill # 2972595 Address 134 LEWIS AVE Unit # / Suite City TYBEE ISLAND Zip Code 31328 - Neighborhood 20222.00 - T222 TYBEE HORSE PEN Total Units Zoning R -1-B Class R3 - Residential Lots Appeal Status Legal Description Legal Description LOT 55 PALM TERRACE SUB SAVANNAH BEACH TYBEE ISLAND Deed Book 397M Deed Page 215 Permits Permit # Permit Date Status Type Amount 10-0389-2 07/28/2010 Complete RF - ROOF $8,950.00 040418-1 10/08/2004 Complete $0.00 Inspection Inspection Date 03/26/2019 Reviewer ID KMMORENO 1 of 4 10/12/2020, 9:33 A Chatham County, Georgia https://www.chathamtax.org/PT/Datalets/PrintDatalet.aspx?pu 04/12/2016 MWTHOMAS 11/24/2010 LESTEPH 05/22/2007 AVMARCAN Appraised Values Tax Year Land Building Appraised Total Reason 2020 154,500 86,800 241,300 2019 153,900 51,400 205,300 2018 153,900 50,800 204,700 2017 170,300 44,700 215,000 2016 170,300 34,700 205,000 2015 173,500 36,000 209,500 2014 173,500 38,200 211,700 2013 173,500 37,700 211,200 2012 173,500 36,200 209,700 2011 173,500 45,300 218,800 Sales Sale Date Sale Sale Instrument Book Grantor Grantee Price Validity Page 07/08/2014 0 U QC 397M - 215 PULFER & BANISTER BERYL ETAL* BANISTER ERIC D ETAL* 05/23/2012 0 U QC 377W - 435 PULFER & PULFER & BANISTER BANISTER ERIC D & ERIC D ETAL* 04/14/2003 0 U QC 2500 - 562 PULFER ERIC D & PULFER ERIC D ETAL SHEILA 07/01/1984 45,453 Q Land Line Number 1 Land Type F - FRONT FOOT Land Code 112 - CREEK/MARSH ACCESS Square Feet 9,600 Acres .2204 Influence Factor 1 -10 Influence Reason 1 Influence Factor 2 Influence Reason 2 Residential Building 2 of 4 10/12/2020, 9:33 Chatham County, Georgia https://www.chathamtax.org/PT/Datalets/PrintDatalet.aspx?p Card # 1 Actual Year Built 1970 Effective Year Built 19$5 Type 1 - Single Family Residence Style/Stories 1 - ONE STORY Percent Complete 100 Quality 200 Condition AV - AVERAGE Living Area 1,116 Basement Area 0 Finished Basement Area No Bedrooms 3 Full / Half Baths 1 / 1 10 A3 10 5 6 4 AI 4 4 4 4 10 Main Building 2 4A24 5 6 33 Item Area Main Building 1116 Al - 904:904 -Slab Porch (SF) with Roof 16 A2 - 904:904 -Slab Porch (SF) with Roof 20 A3 - 907:907 -Enclosed Porch (SF), Scree 100 3 of 4 10/12/2020, 9:33 A Chatham County, Georgia https://www.chathamtax.org/PT/Datalets/PrintDataletaspx?pin= f4 10/12/2020, 9:33 AM 9/26/2020 Details �� laCeTi \`J Licensee Details Licensee Information Name: Willis D LaRose Address: 137 New Cut Rd. PROFESSIONAL LICENSING GEORGIA SECRETARY OF STATE BRAD RAFFENSPERGER CORPORATIONS • ELECTIONS • LICENSING • CHARITIES Winder GA 30680 Primary Source License Information Lic #: GCI000175 Profession: Residential/General Contractor Type: General Contractor Individual Secondary: Method: Application/Exam Exempt Status: Active Issued: 4/21/2008 Expires: 6/30/2022 Associated Licenses Public Board Orders Other Documents Last Renewal 4/22/2020 Date: No Prerequisite Information Please see Documents section below for any Public Board Orders No Other Documents Data current as of: September 26, 2020 22:52:23 This website is to be used as a primary source verification for licenses issued by the Professional Licensing Boards. Paper verifications are available for a fee. Please contact the Professional Licensing Boards at 844-753-7825. verify.sos.ga. nov/verification/Details.aspx?result=17424992-87de-498f-a910-4d 057ea2fe3e 1/1 Economicand Community Development 30 N. Broad Street Winder, GA 30680 Occupational Tax Certificate 2020 Business Name: Mailing Address: Phone: Business Location: Only valid at this location and when conforms to Barrow County Ordinances. This is to certify that the person or firm named herein has paid into my hands minimum payment of occupational tax as set out herein and benefit of the county aforesaid, and is licensed to engage in the business listed on this certificate. Category: Type: ,. NAICS: FOfF, LLUCV AAA GENERAL CONTRACTORS 137 NEW CUT ROAD WINDER, GA 30680 770-560-0090 137 NEW CUT RD WINDER GA 30680 RESIDENTIAL CONSTRUCTION SINGL RESIDENTIAL CONSTRUCTION SINGL •236115 License Number 199 Issue Date: 12/30/2019 Expires: 12/31/2020 EXEMPT YES / NO Y HOME OCCUPATION Y Total Received: 60.00 POST IN A CONSPICUOUS PLACE THIS LICENSE IS NOT TRANSFERABLE tpiro--usie,ess£arrW6.+.-0eet ai�•r STATE ATE OF GEORGIA Secretary of State Corporations Division 313 West Tower 2Marten Luther king, Jr. Dr. Atlanta, Georgia 30334-1530 ANNUAL REGISTRATION BUSINESS (INFORMATION CONTROL NUMBER BUSINESS NAME BUSINESS TYPE EFFECTIVE DATE ANNUAL REGISTRATION PERIOD PRINCIPAL OFFICE ADDRESS ADDRESS *Electronically Filed* Secretary of State Filing Date: 1/8/2020 5:08:37 PM 0464673 - AAA GENERAL CONTRACTORS, LLC Domestic Limited Liability Company 01/08/2020 2020, 2021, 2022 137 New Cut Road, WIiVDER, GA, 30680, USA REGISTERED AGENT NAME ADIIRESS WILLIS D. LAROSE 137 New Cut Rd., WINDER, GA, 30680, USA AUTRORMIROFORNIATIO AUTHORIZER SIGNATURE Willis D. LaRose AUTHORIZER TITLE Organizer COUNTY Barrow ATTACHMENT B O.C.G.A. § 50-36-1(e)(2) Affidavit By executing this affidavit under oath, as an applicant for a(n) contract for a public benefit as referenced in O.C.G.A. § 50-36-1, from the CITY OF TYBEE ISLAND, Georgia, the undersigned applicant verifies one of the following with respect to my application for a public benefit: 1) X I am a United States citizen. 2) I am a legal permanent resident of the United States. 3) I am a qualified alien or non-immigrant under the Nationality Act with an alien number issued by the Security or other federal immigration agency. My alien number issued by the Department of Homeland immigration agency is: The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has provided at least one secure and verifiable document, as required by O.C.G.A. § 50-36-1(e)(1), with this affidavit. Federal Immigration and Department of Homeland Security or other federal The secure and verifiable document provided with this affidavit can best be classified as: In making the above representation under oath, willfully makes a false, fictitious, or fraudulent guilty of a violation of O.C.G.A. § 16-10-20, criminal statute. Executed in IATI. r (city), I understand that any person who knowingly and statement or representation in an affidavit will be and face criminal penalties as allowed by such (state). 42. Signature of Applicant b): 1 1` s / 7. L- Printed Name of Applicant .�1 SUBFftr..AZiVti WORN BEFORE ME ON THE aU DAY OF ?4c e , 20 ao NCOdky My- itiiittOsibcn ', 06, ..Q le a0 i%� G EO?' .\ 4///1111 ATTACHMENT G CERTIFICATION REGARDING DEBARMENT Certification Regarding Debarment, Suspension, Ineligibility And Voluntary Exclusion Subcontractor Covered Transactions (1) The prospective contractor, AM General Contractors of the Sub -Recipient certifies, by submission of this document, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. (2) Where the contractor is unable to certify to the above statement, the prospective contractor shall attach an explanation to this form. CONTRACTOR AAA General Contractors By: Signature Willis D. LaRose 137 New Cut Road Winder, Georgia 30680 20 March 2020 City of Tybee Island Sub -Recipient's Name Name and Title Street Address City, State, Zip Date Form .9 (Rev. October 2018) InternalInDepartment Revenue ServiTreasury 0 p o v Request for Taxpayer Identification Number and Certification I. Go to www.irs.gov/FonnW9 for Fnsm latest 1 Name (as shown on your income tax retum)�Name is required on this line; do not vte this nandeb an information. 2 Businessname/disregard:. entity name, if different from above 4 c 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes. 0 Individual/sole proprietor or 0 C Corporation I sin S Corporation ❑ 9 e matsb r LLC ora n Partners hip ❑ Trust/estate 0 Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ► tIC if Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check the LLC is that is classified tt disregarsingle-member the oLLCr forthat Sdf� d ral isregarded fromt the owner unless the owner of the LLC is 0 is disregarded from the owner should check the appropriate box for the a ciclassssifica ion of its owner.r.member LLC that Other (see instructio ns) ► 5 Address (number, street, and apt. or suite no.) See instructions. (37 Otte- ��. 6 City, state, and ZIP code 7 list account number(s) here (optional) V ! `" Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see flow to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. Give Form to the requester. Do not send to the IRS. 4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3): Exempt payee code (d any) Exemption from FATCA reporting code (if any) to s to accounts mined outside a» U.S.) Requester's name and address (optional) Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification Instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax retum. For real estate transactions, item 2 does not acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct N. See the nstrructionsefo Partdil, later. Sign Here u.s.person► Lv Signature of t, '� or General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (MN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information retum. Examples of information returns include, but are not limited to, the following. Form 1(}99-INT (interest earned or paid) Cat. No. 10231X Date ► G ! f 4C LAG=_!, , • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-5 (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding See What is backup withholding, later. Form W-9 (Rev. 10-2018) �. fit% j)�'.V(J /3 +►.�� CERTIFICATE OF LIABILITY INSURANCE THIS DATE {p1>:11DD/YYYy) CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THEE CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policylies) must have ADDITIONAL INSURED provisions or be en tEa If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement this certificate does not confer rights to the certificate holder In lieu of such e ndorsement(s), endorsed. PRODUCER on Insurance Center c • ACT Brett Ganfin CE 125 W. Athens St. Winder, GA 30680 INSURED AAA General Contractors, LLC 137%w Cut Rd. Wader, GA 30680 COVERAGES PHoNs . (770) 867-7441 Chasity@Winderinsclr.com FA X No (770) 867-1234 CERTIFICATE NUMBER: ---��_ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED INDICATED. NOTWITHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCU�NTSW WITH UMBER CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I SUBJECT TO ALL THE VE FOR THE POLICY PERIOD ILTREXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS RESPECT TO WHICH THIS TYPE OFINSURANCE ADDL 8 R A , ' POLICY NUMBER ^�" COMMERCIAL GENERAL LIABILITY CLAIMS -MADE C OCCUR GEML AGGREGATE LIMIT APPLIES PER O - POLICY ECT LI LOC UMBRELLAUAB OCCUR EXCESS LIAR CLAIMS -MADE DED RETENTION 8 1 WORKERS COMPENSATION AND EMPLOYERS' LIAEILfTY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory 1n NH) 1f yes, describe (alder DESCRIPTION OP OPERATIONS below 80599623 WC5-39S-729722-D19 10/11/2019 10/22/2019 0/11/2020 ! EACHOCCLPRENCE P •.I occurerre MED EXP (Any ore person) $ 5,000 PERSONAL & ADV INJURY '. GENERAL AGGREGATE s 2,000,000 PRODLCTS - COMP/OP AGG 10/2212020 ! VI TUT 1 E.L EACH ACCIDENT EL DISEASE - EA EMPLOYEE EL DISEASE -POLICY UMIT DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required) CERTIFICATE HOLDER Donna and Larry Rper 127 Lewis Avenue Tybee Island, GA 31328 ACORD 25 (2016103) CANCELLATION THE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED ED BEFOR ACCORDPANCE IRTH THE OLICYPROV1TION DATE THEREOF, NOTICE WLL BE D©-Nr:RED IN AUTHORED REPRESENTATIVE Olt/ 00.:6t tab -3.44449v The ACORD non% and logo are registered ma19061015 rks of ACORD 41iD c©�DRATION. Ali rights reserved. ATTACHMENT D CITY OF TYBEE ISLAND VENDOR INF RMATI N Vendor Name: AAA General Contractors Product or Services Provided: General Contractor, designer of project, project manager, accounts payable and receivables, coordinator of production, carpenter, Back hoe digger, footer design and builder, floor system installer, etc. Sales Contact Information Contact: _Willis D. LaRose Email _willla@windstream.net Phone: _cell 770-560-0090, home/office 770-867-7241_ Fax: _770-867-7257 Address: _137 New Cut Road, Winder, Georgia 30680 Accounts Receivable Information Contact: _SAME AS ABOVE Email: _SAME AS ABOVE Phone: _SAME AS ABOVE Fax: _SAME AS ABOVE Remittance Address: _SAME AS ABOVE Federal Tax Id #: _20-2248371 Attach Copy of W-9 and Occupational Tax Certificate Provide Copy of Worker's Comp Coverage when providing any service involving labor on City Our terms are net 30 property. 3Cck,le I/8` 6f, riot IL Iroo* R. be 1 rI3 7 gs lJe .Z7 # � T. � 2 141 �I� 1 .* 1 .,-ter ,If ci'e 8 rt.° m►Toni/ Pr • 1.2"7 iz,,y tibv5.1•<9: 20 sr • %r ♦" I432 0 z i 4 41 4444 N., 4444.444. .53 `f .54 It �►1 440 444.41440444414. 4 ,4 jp 114 or .0...1,..... .E ,4,.4..■ 49 s,(4- .�.s 4NG es - .,omen 1444 44 .,. .,,. 1Qa e. 15: /05 fliv) 5-ta,;(*-4P.Ad_7 Case RNRectrv •F La 755 Nagle a %i S7 4.4.4444.4114 44. 4144411111, .3•8 132 I314Le lSh e r 44. khar 44°4460(1- s,#))%1 6\ ‘" o N1*— MOW seosps y - &>. 401900 igt °IOW WO ON04'? µ0E V£ 4g1au grat eVi Meth "S s.11tla�W ti a 13 1 '��d�� OQ3 30 � 1N����t�1W ��1� 001, O LAM Sla6 g� � .�e1 �30� .�" 4�4iµ1 'Z,:k` 3atie�^ w+u�,ao OS \ fi10 14. 3, O� X18 ��o� ;1, N � ASS \D, © 11� �� 11��S�1 S110S s1�ah a,a� an Di'd S� .11��15as `;n Haan z a, z� � . 12. 1S° ‘sr ��►s as � 'n� zat Qa"� �asor'''e x' 01 1 � r3 1 t‘ Q� �@ �� Sim �ati u>ea 3�,,d� ° %r\ ; 4�©1 Ss� �d s�1� � au� }o`o o� 1 p1Oga ` Q H�N1 �0�%%0 kk aG se ,Qa11 + 01 pati+C,1'11�$ �,� ea��+�� 13 O da 1P� 3tinssa�a1hp11�d h� 1%.%01-3 t�r� � 1-4 ))„,-,4 ` Z - `�1 iC L N1 41z�Gu�' 3�10 to t is abo ng Nasiacss More UO. abov %g �dE =�ykSe 3 F°:G e o 004 0.4StIrOst:0; MttjtNit��ll Special Flood Hazard Zones Finished floor elevation 1 foot minimum above BFE. No interior finishes, walls designed to allow entry and exit of water, no mechanical equipment, only parking, limited storage and building access BFE. Fliocd hazard zone A. BFE No interior finishS, wails designed to allow entry and exit of water, no mechanical equipment. Only parking, limited storage and building access below BFE. n Po Se Co VeCtisa �' t 1�9 01011 r VC, COQ$' COV to i�e`le aae by r'CY bagb,eeo`e 5�d a+� set ��6® IOCIA Ort to e. it 1 an' be co alt r oi��an e o f 03 1`Q �Q Qo ,e, o Del• or o�� a c Cd e� o Ogg a E10 S®� Iell 'the c t s'aoul tQe • . Ica i Or an Se��ow��S�,tY sria �' at IP k,tfo•c-J9, 0)- %° 4«,\)-cc,f<9 �a a CITY OF TYBEE ISLAND BUILDING & Z ' ING DEPARTMENT APPROV ZONING 4 WILDING/CORE DATE WATER/SEWER ©F AIN,A $0 IL & SEDIMENT CLOTK IN PLACE