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PERMITAPPOCATION <br /> DRIVEWAY PERMIT.APPUCA1- 30N <br /> =NSTRUC73ON•WITHIN;PUBL-IC RIGH'!'•-OF-WAY <br /> NI InformaUo6 MLs5t be filled-ln completely <br /> CCity.of.2ephyrhllls- <br /> 'S335 8B1 Street Zephyrhlils,FL 3.3542 <br /> Telephone 813.780.0000 Fax 813.780.0005 <br /> (Datoofappileitloni ;' Procseil'By7 ( oPerinit,#e:, <br /> ;�Co�/.tu.Buldl` Dc itrtknt_ pytplod)UcWorks <br /> :PROJECT 3OB'SITE: -�4f I�% r" PROPERTYTOWNER. <br /> Address r C/ <,� > ' r'e? - '� Name: — <br /> Unit#: , 4 '► S, Z.Address: -5-• �l✓it ol;;.�Unit <br /> ParcelIdentlBarUon fiumbtr. Cit State ZI - <br /> L _ <br /> :CONTRACTOR: <br /> :CcmaanY: <br /> Name <br /> ContriicWs Umnse#: E-Mall: <br /> Phone: Cell: Fax:- <br /> ARCHOEMENGINEER: <br /> Name. Firm Name: <br /> Address: CItV: State Zip: <br /> State Ucmm#:. Phone:. Cell: Fax:- <br /> DescrirAlon <br /> r- <br /> Q LENGTH Or-DRIVEWAY CULVERTS'NEETH D <br /> AESMEBTIA1 DRIVEWAY /v WIDTH B OF DRIVEWAY ( )MNFORaD ETE <br /> _=MMERCILL DRIVEWAY. FLO. .. EXCAVATION ( )CORRUGATED MATEFUAL <br /> AO=DRIVEWAY _DM _LINEAR FEE r ( )BOX aXVIRtT . <br /> CONS1RUCftOIV MATERIAL CURB CUT REOU1ttED ( ) � <br /> ---AlS7M'T YES _NO <br /> +�%Q3TrO'1ETE <br /> HEADWALL REOUFRM -YES -N <br /> NOT CE TO APPLICANT: If actial work exceeds scope of this description,adddlonal permits or drawings <br /> will be required. <br /> UTILITY LOCATIONS REQUIREDi CALL BEFORE YOU DIm i so0A32A770 <br /> Page 1 of 3 <br /> I <br /> l <br /> l <br />