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<br /> <br />STATEMENT OF COMPLETION AND REQUEST FOR <br />., TRANSFER TO OPERA nON ENTITY <br /> <br />SOUTHWEST FLORIDA <br />WA TER MANAGEMENT DISTRICT <br /> <br />'~~ ol <br />~13268. ~ <br /> <br />2379 BROAD STREET. BROOKSVILLE, FL 34609-6899 <br />(904) 796-7211 OR FLORIDA WATS 1 (800) 423-1476 <br /> <br />Within 30 days after completion of construction of the surface water management system, the owner or <br />authorized agent must submit the original plus one copy of this fonn and two complete sets of certified as- <br />built drawings for the surface water management system structures and appurtenances. Upon receipt, this <br />Statement of Completion will be reviewed and the system may be inspected for compliance with the <br />approved pennit and as-bullt drawings. The operation phase of this pennit is effective when the Statement <br />of Completion fonn is signed by an authorized District representative. <br /> <br />1. SURFACE WATER MANAGEMENT SYSTEM INFORIIAnON: <br />Pennlt No.: 't 3 /3 26 go .. 0 I County: P4-s co <br />Project Name: 0 tscov~ 4-ur-o (7A-rf.1> - S/OfL-€ #- S;f.{ t< <br />Pennittee: C try of 'Z--rl'ffYfL.l-il(.(S <br />Address: 5 3$> [lG-Hrl~ ~TMr;-?- <br />City, State, Zip: '2.-?fW""'/c-l-ftus F L '3 '7 5'10 <br />Telephone: ( j' ''It 7 g- f! - b {. II <br /> <br />~A. <br /> <br />I HEREBY CERTIFY THAT (please choose accurately and initial only one box): <br /> <br />At the time of final Inspection, the surface water management system was completed <br />substantially In accordance with the pennitted construction plans and infonnation. Any <br />minor deviations from the pennitting plans and specifications will not prevent the system <br />from functioning in compliance with the requirements of Chapters 400-4, and 4OD~, or 400- <br />45, F .A.C. (The as-built drawings and infonnatlon submitted to the District shall confinn this <br />certification. ) <br /> <br />B. At the time of final Inspection, the Bystem was not completed In substantial confonnance <br />with the pennltted construction plans and Infonnatlon. (The registered professional engineer <br />shall explain in writing, and with confinning depiction on the as-built specification. In this <br />case, the professional engineer shall complete, but not sign and seal, the Statement of <br />Completion.) <br /> <br />This certification shall be verified by TWO COPIES of attached "as-built" drawings (as-built drawings must <br />be signed, dated and sealed by a Registered Professional Engineer or Land Surveyor, as required by State <br />Law). <br /> <br />By: <br /> <br />~.. <br />Signature of Engineer of Record <br /> <br />" <br /> <br />SA MHI E L k.lfoc../ <br />Name (p/fNlse type) <br /> <br />S P I2.J IV&. E'IV 6r1W; S tL4 ~ J <br />Company Name <br />'301 L{ &5 <br />Company Address <br />1-1 G> L I r?.4., F L <br />City, State, Zip <br />1012 <br /> <br />4f ~6 2- <br />FL P.E. No. <br />l~ <br /> <br />Date: <br /> <br />-AFFIX SEAL- <br />U/S/9C <br /> <br />1/ '-., <br /> <br />/9. <br /> <br /> <br />fV~91 <br />