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<br />_.._-~ <br />"S;Jf.. .~ <br />I ~ <br />~, <br /> <br />ST..\T1; OF FLORID/. Dt::'AATMENTOF TAANSI'ORTAl1ON <br />DRIVEWAY/CONNECTION APPLICATION <br />FOR ALL CATEGORIES <br /> <br />fOltM 'lo-OI~1l <br />sysn;...s PUVININO. I t~ <br />..... I or6 <br /> <br />1--- OFFK:E USE ONLY <br /> t:J/ -.4 - 79 f- C;()~/ .- : J.l/c-k~,v~ <br />Application Number: . . ~By: <br /> .- ,I" -0- rDOTr.Ar?(1T1'IlOll-'Tl <br /> # : -, <br /> - ~ .. .3--?-7-u/. <br />C lllellol) . ." .: . Dace: <br />-. o. <br /> .. . -- .-. - 0- <br /> <br />-APPLICA COMPLETE REMAiNDER OF FORM <br />PART ':Arri.lCANTINFORMATiol'i' ." ~ ' -. <br /> <br />"fPLICANT: CbrtR.E.\ ~ f~(Y\ \~ f.J:."D~&.f:;. CONSULTING FlRMIPROJFCT MA~"G[R: <br />Mailing Address: l1'~~ ~\ L.:7-"H N; L..N<€ ~\VE vi, f. c....:. ~ "lG.1 \--~ I'-\(" ,1t-I <- .. <br /> <br />City,Sl:Ik, Zip Z-SPt\,f4l11_L-'S -fL. '536"4L_ WllL/A}"" f" \ 4f-\tE~f\Js_~_________ <br /> <br />rclepJtont': ( <it.> I 11 ~ - 75 <6~ ._ IAn Q 1/ ~ ~ 0 1..-' OJ.. Cl: <br />Mailillll Address:..!:] ,I. "'" 0 I~ r I r t:: r L-A <br /> <br /> <br />PROPER1YOW:-lER:~A rkl\\\1 ~V~ <br />TR-v...-SI <br />R.!sponsible Corponlle omu:~- __ <br />Mllilir.g Addres!' lo 74\ "\O\L}l\ lAK~ ~"t <br /> <br />Cil)".Sl:)~,Zip ZE.f~rl..l.\IU-~ R-. 3~S-1L- <br />rele?hOnf:8(~ (I So - 1 c;~g <br /> <br />FAX !\.lobi1e Phone, tIC.. ~l; - 1 ~'K - 9 s \ ~ <br /> <br />City SIBle. Zip: <br />'TJ\JY\Pp.. 1 VL-, 3~{,2-~- <br /> <br />Tclephone~} Zl,,4 -1(,':)0 <br /> <br />FAX Mobile Phone, elc":~_]Q ~ - 3.3 1 ~ <br /> <br />\CII('LI 0Ntl <br /> <br />{CIIl:Lf CHFl <br /> <br />ARE YOlJ AN AUTHORJZED REPRESENTAl"IVE? <br /> <br />lfthe property owner desires to have a representative ~ign and handle the application, lhe owner must provide <br />a nOlarized teller of authorization attached with the a lication. SEE PART 2 OF nns fORM BELO <br />PART 2: Al'PLICANTS AUTHOIllZA TION OF REPRESENTATIVE <br /> <br />Aulhori1:ltd Rt'prtsenutivt: <br /> <br />. <br /> <br />(NOTE: All c:or"''POndrn("t will be madoe U'roulh tht rtpreNlltatlvt. A 11(\("-'" letlu or.uthorlatlon must be attuh<<llfyou ue an <br />alllhorbed rfpnHnutlvt., <br /> <br />Su.'lllr <br /> <br />Company. <br /> <br />^ddr>:ss: <br /> <br />Continue ooto "en P'lge <br />