HomeMy WebLinkAbout2008 FDOT Driveway Connection Permit STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 850-040-15
DRIVEWAY/CONNECTION APPLICATION SYSTEMS PLANNING
04/05
FOR ALL CATEGORIES Page 1 of 3
OFFICE USE ONLY
Application Number: Received By: - ` . r-1; <_"
FDOTeSTAFF(TYPE OR PRINT)s:
Category: _ Date: (. �.
Sectidn/Mile Post: I State Road:
Section/Mile Post: / State Road:
Instructions-To Applicant
• Contact the Department of Transportation to determine what plans and other documents you are required to submit with your application.
• Complete this form(some questions may not apply to you)and attach all necessary documents and submit it to the Department of
Transportation.
• For help with this form contact your local Maintenance or District Office.
• Or visit our website at www.dot.state.fl.us/onestoppermitting for the contact person and phone number in your area.
• You may also email-driveways @dot.state.fl.us
• Or call your District or local Florida Department of Transportation Office and ask for Driveway Permits.
Please print or type
APPLICANT:
C1heck one:
(g Owner -`Q Lessee„ 0 (Contract to Purchase
Name: 1� (, S 10( \
Responsible Officer or Person: N' `A, tiYt Y C ' b\ mono t
If the Applicant is a Company or Organization,Name:
Address: \ 115 u 1 S
City,State:
Zip: 51 Phone: l 111) ; ) B G - 5 ")3 l/ Fax: ( 11 ) 5C1 J 5 1
Email: i\ M 1 Il i if V & C F U 1 st ro J I ' U I 1 01c-
LAND OW`N iER$:}((iif not applicant)) ` f
Name: 1\) Ill . (1I1 I U S G p Ill \t f i •
If the Applicant is a Company or Organization,Name:
Address:
City,State:
Zip: Phone: Fax:
Email:
850-040-15
SYSTEMS PLANNING
04!05
Page 2 of 3
AUTHORIZED REPRESENTATIVE: If specified by Applicant to handle,represent,sign,and file the application-
NOTE: A notarized letter of authorization must be provided with the Application
Name: M1911 S c R 1 p I P
Company Name: J,c\ \\K�C 1 B ‘1 .1 \I , S1(Judaic\ 11_.1 C
Address: `A ,\ man MI), o' V .) '.J Ut 70
City,State: V l Y() l 1,k\ I 1 1 r i
Zip: 310,q() Phone: (1111 T()- Oi n 71 Fx: (111) 110." Q`i
Q t
Email: 1 SCwq \ @ NimoLr .-s.
to
Address of property to be served by permit(if known):
� �} ffil , 5 ► dui, 0101CjSi
(`' 1}r, 'tp g/ '1 1 li tre t c/such as 500ifeet south of Main St.)
If adtft`i5s�s not krio�n,provl������ce`From�earest mtersectlrig�ub c s e ( ,
Check here if you are requesting a
O new driveway temporary driveway Q modification to existing driveway Cr safety upgrade
Does the prope owner own or have any interests in any adjacent property? •
Io No Yes,if yes-please describe: A�1 \(j c-p 1f1 i \o n C� S `\l I w . y J . i mom n S }
Ar� ,� ((; '1 ` U to 1. g
tHele h e iS� j-tr d L ted i streets,roads,highways or access easements bordering or within the property?
0 No Yes,if yes-list them on your plans and indicate the proposed and existing access points. 100 U 10 y , an a I/t v t .
Local Government Development eview or Approval Information:
Local Government Contact: i 1l . 11\\ 1 cll.) \( (i\ 1V \ c S u0 lI \vtd
\ oN
t ni i i t y
Name: CUI ' n-t C\-\\k ` ,k\ st 0 c\)(i )
Government Agency:
Phone#:
850-040-15
SYSTEMS PLANNING
04/05
Page 3 of 3
If you are requesting commercial or industrial access,please indicate the types and number of businesses and provide the floor area square
footage of each. Use additional sheets if necessary.
Business(Name and Type) Square Footage Business(Name and Type) Square Footage
1. 1V 3.
2. 4.
If you are requesting a residential development access,what is the type(single family,apartment,townhouse)and number of units?
Type Number of Units
11 ��
Provide an estimate of the daily traffic volume anticipated for the entire property at build out. (An individual single family`home,fduplex,or quad�-7plex2
is not required toi complete etthis section). Ni f\ tit S\I\ vuol C R� • Nu m �+ J 3 tr f (lu y i
� T�ff1 f t� 1V � I, l.n
Daily ra Ic s Ima e= u Q. fthe latest Institute of Transportation Engineers(ITE)Trip Generation Re ort)
If you used the ITE Trip Generation Report,provide the land use code,independent variable,and reference page number.
ITE Land Use Code Independent Variable ITE Report page number reference
Check with the Florida DOT Office where you will return this form to determine which of the
following documents are required to complete the review of your application.
Plans should be 11"x 17"(scale 1"x 50') f) Proposed access design
Note: No plans larger than 24"x 36"will be accepted g) Parcel and ownership maps including easements(Boundary Survey)
a) Highway and driveway plan profile h) Signing and striping plans
b) Drainage plan showing impact to the highway right-of-way i) Traffic Control/Maintenance of Traffic plan
c) Map and letters detailing utility locations before and j) Proof of liability insurance
after Development in and along the right of way k) Traffic Impact Study
d) Subdivision,zoning,or development plans I) Cross section of roadway every 100'if exclusive turn lanes are
e) Property map indicating other access,bordering roads and streets required
Important Notices to Applicant Before Signing Application
The Department Reserves The Right To Change Traffic Features And Devices In Right Of Way At Any Time
Proposed traffic control features and devices in the right of way,such as median openings and other traffic control devices,are not part of
the connection(s)to be authorized by a connection permit. The Department reserves the right to change these features and devices in the
future in order to promote safety in the right of way or efficient traffic operations on the highway. Expenditure by the applicant of monies
for installation or maintenance of such features or devices shall not create any interest in the maintenance of such features or devices.
Significant Changes In Property Use Must Undergo Further Review
If an access permit is issued to you it will state the terms and conditions for its use. Significant changes in the use as defined in Section
335.182(3),Florida Statutes, of the permitted access not consistent with the terms and conditions listed on the permit may be considered
a violation of the permit
All Information I Give Is Accurate
I certify that I am familiar with the information contained in this application and that to the best of my knowledge and belief,such
information is true,complete and accurate.
Starting Work On The Driveway Connection After I Get My Permit Means I Accept All the Conditions In My Permit
I will not begin work on the connection until I receive my Permit and I understand all the conditions of the Permit When I begin work on
the connection,I am accepting all conditions listed in my Permit
Applicant Name(Printed): \ , , ntf.
Applicant's signature: / ��. Date c)(Zlo t
STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 850-040-16
RECEIPT OF CONNECTION APPLICATION SYSTEMS PLANNING 06/06
AND FEE (OR WAIVER OF FEE)
I IMPORTANT NOTE: Even though your application has been accepted, it may not be
complete. We will contact you if more information is needed.
(1) APPLICATION NUMBER:
APPLICANT: p 1(�(i (t
(2) Name/Address J\ V I 1 vu AlUf J .i M\f\nl V , Cl\y monQq tI/
1 1llin ti`
(3) Project Name: 0.,0. 1i1 of s i Y I \n61g f I WO Ov\v-t Impnvtrnt At S
VEHICLES PER DAY FEE
(4) Fee 0 Category A 1-20 $50.00 p)
Q Category B 21-600 $250.00 ��/e
) V"-
Q Category C 601-1,200 $1,000.00 , Q/ 4'Au y
Q Category D 1,201-4,000 $2,000.00 Ir
Q Category E 4,001-10,000 $3,000.00 Id
Q Category F 10,001-30,000 $4,000.00
Q Category G 30,001 + $5,000.00
yii Temporary $250.00
• - e y NO FEE
Q Government Entity NO FEE
(5) Application Fee Collected $ a - (6) Fee Collected By
Payment Type: Name .. ... a®'=-e .;
Money Order 0 �R .
Signature __ .- � �� ., .
Check 0 Check Number u - --_
Cash Cr Date: •''''t ; ,..::-1 c 'District Unit
(7) Receipt Given Back to Applicant Via
0 Hand Delivery Q Mail Q Courier Service 0 Other
Applicant(or Agent)Signature(if available)
This form bears your application number and serves as your receipt.
(8) If fee is waived,give justification below or on separate sheet.
FOR AGENCY USE ONLY-ATTACH COPY OF CHECK ON THE NEXT PAGE
Make Checks payable to: State of Florida Department of Transportation
•
STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 850-040-18
SYSTEMS PLANNING-06/06
DRIVEWAY CONNECTION PERMIT Page 1 of 3
FOR ALL CATEGORIES
PART 1: PERMIT INFORMATION
APPLICATION NUMBER:
Permit Category: p p N �( (� Access 1Cllla�ssificatti/on: n y�/� (�
Project: �,u. ( i S� `. 1' 1∎rir\RIOTCY lV tY DY1Vt ,I \ yVV mtn\ s ��I ' `� ovi of og.sit C�c( 5 (M TY(-t
Section/Mile Post: A 7 NO ( \G 145 C1 State Road: \ �} t U S ' ,
Section/Mile Post: State Road:
PART 2: PERMITTEE INFORMATION
Permittee Name: 1\� St Ut`Gn ; j\ MinVnt V - c i\\. mgn( gt E
Permittee Mailing Address: \\15 1A(.\'n S
City,State,Zip: \'t 1 \\c,f\ 3 L 5 0
Telephone: hi 1) 13A- 5336
in onsultant/or Pro ject Manager: t, 8
11
Engineer responsible for construction inspection: t \tf i , )
NAME P E
Mailing Address: 11 n \\UO n ,\f B t 1 U j Witt ! 0
City,State,Zip: V-t Y f)t a Cpc (lc
4 ,1
! q jj - Qt-10
Telephone: (111 1-1 V Q lX 1 2 FAX, Mobile Phone,etc. [111, 1111 U'
PART 3: PERMIT APPROVAL
The above application has been reviewed and is hereby approved subject to all Provisions as attached.
Permit Number:
/ D ent of Transportation nay
Signature: Title: ]OHH SPIVEY
Repr/entative's Printed Name Contract/Perm Manager
Temporary Permit •YES Q NO (If temporary,this permit is only valid for 6 months)
Special provisions attached Q YES Q NO
Date of Issuance: I /O /O&n
If this is a normal(non-temporary)permit it authorizes construction for year from the date of issuance. This can only be
extended by the Department as specified in 14-96.007(6).
See following pages for General and Special Provisions
VMS, Inc.- Fernando Ojeda
420 4th LN SW 850-040-18
SYSTEMS PLANNING-06/06
Vero Beach, FL 32962 Page 2 of 3
TE 772-299-1554
PART 4: GENERAL PROVISIONS
1. Notify the Department of Transportation Maintenance Office at least 48 hours in advance of starting proposed work.
Phone: ,Attention:
2. A copy of the approved permit must be displayed in a prominent location in the immediate vicinity of the connection
construction.
3. Comply with Rule 14-96.008(1), F.A.C., Disruption of Traffic.
4. Comply with Rule 14-96.008(7), F.A.C.,on Utility Notification Requirements.
5. All work performed in the Department's right of way shall be done in accordance with the most current Department
standards, specifications and the permit provisions.
6. The permittee shall not commence use of the connection prior to a final inspection and acceptance by the
Department.
7. Comply with Rule 14-96.003(3)(a), F.A.C., Cost of Construction.
8. If a Significant Change of the permittee's land use, as defined in Section 335.182, Florida Statutes, occurs,the
Permittee must contact the Department.
9. Medians may be added and median openings may be changed by the Department as part of a
Construction Project or Safety Project. The provision for a median might change the operation of the connection to
be for right turns only.
10. All conditions in NOTICE OF INTENT WILL APPLY unless specifically changed by the Department.
11. All approved connection(s)and turning movements are subject to the Department's continuing authority to modify
such connection(s)or turning movements in order to protect safety and traffic operations on the state highway or
State Highway System.
12. Transportation Control Features and Devices in the State Right of Way. Transportation control features and
devices in the Department's right of way, including, but not limited to,traffic signals, medians, median openings, or
any other transportation control features or devices in the state right of way, are operational and safety
characteristics of the State Highway and are not means of access. The Department may install, remove or modify
any present or future transportation control feature or device in the state right of way to make changes to promote
safety in the right of way or efficient traffic operations on the highway.
13. The Permittee for him/herself, his/her heirs, his/her assigns and successors in interest, binds and is bound and
obligated to save and hold the State of Florida, and the Department, its agents and employees harmless from any
and all damages, claims,expense, or injuries arising out of any act, neglect,or omission by the applicant, his/her
heirs, assigns and successors in interest that may occur by reason of this facility design, construction,
maintenance, or continuing existence of the connection facility,except that the applicant shall not be liable under
this provision for damages arising from the sole negligence of the Department.
14. The Permittee shall be responsible for determining and notify all other users of the right of way.
15. Starting work on the State Right of Way means that I am accepting all conditions on the Permit.
850-040-18
SYSTEMS PLANNING-06/06
Page 3 of 3
PART 5: SPECIAL PROVISIONS
NON-CONFORMING CONNECTIONS: Q YES Q NO
If this is a non-conforming connection permit,as defined in Rule Chapters 14-96 and 14-97,then the following shall be a part of
this permit.
1. The non-conforming connection(s)described in this permit is(are)not permitted for traffic volumes exceeding the Permit
Category on page 1 of this permit,or as specified in"Other Special Provisions"below.
2. All non-conforming connections will be subject to closure or relocation when reasonable access becomes available in
the future.
OTHER SPECIAL PROVISIONS:
PART 6: APPEAL PROCEDURES
You may petition for an administrative hearing pursuant to sections 120.569 and 120.57,Florida Statutes. If you dispute the facts stated in the
foregoing Notice of Intended Department Action(hereinafter Notice),you may petition for a formal administrative hearing pursuant to section
120.57(1),Florida Statutes. If you agree with the facts stated in the Notice,you may petition for an informal administrative hearing pursuant to
section 120.57(2),Florida Statutes. You must file the petition with:
Clerk of Agency Proceedings
Department of Transportation
Haydon Burns Building
605 Suwannee Street,M.S.58
Tallahassee,Florida 32399-0458
The petition for an administrative hearing must conform to the requirements of Rule 28-106.201(2)or Rule 28-106.301(2),Florida Administrative
Code,and be filed with the Clerk of Agency Proceedings by 5:00 p.m.no later than 21 days after you received the Notice. The petition must
include a copy of the Notice,be legible,on 8 1/2 by 11 inch white paper,and contain:
1. Your name,address,telephone number,any Department of Transportation identifying number on the Notice,if known,the name and
identification number of each agency affected,if known,and the name,address,and telephone number of your representative,if any,
which shall be the address for service purposes during the course of the proceeding.
2. An explanation of how your substantial interests will be affected by the action described in the Notice;
3. A statement of when and how you received the Notice;
4. A statement of all disputed issues of material fact. If there are none,you must so indicate;
5. A concise statement of the ultimate facts alleged,including the specific facts you contend warrant reversal or modification of the
agency's proposed action,as well as an explanation of how the alleged facts relate to the specific rules and statutes you contend
require reversal or modification of the agency's proposed action;
6. A statement of the relief sought,stating precisely the desired action you wish the agency to take in respect to the agency's proposed
action.
If there are disputed issues of material fact a formal hearing will be held,where you may present evidence and argument on all issues involved
and conduct cross-examination. If there are no disputed issues of material fact an informal hearing will be held,where you may present
evidence or a written statement for consideration by the Department.
Mediation,pursuant to section 120.573,Florida Statutes,may be available if agreed to by all parties,and on such terms as may be agreed upon
by all parties. The right to an adminstrative hearing is not affected when mediation does not result in a settlement.
Your petition for an administrative hearing shall be dismissed if it is not in substantial compliance with the above requirements of Rule
28-106.201(2)or Rule 28-106.301(2),Florida Administrative Code. If you fail to timely file your petition in accordance with the above
requirements,you will have waived your right to have the intended action reviewed pursuant to chapter 120,Florida Statutes,and the action set
forth in the Notice shall be conclusive and final.