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HomeMy WebLinkAboutDRAINAGE CONNECTION PERMITRULE 1488.004, F.A.C. STATE OF FLORIDA DEPARTMER OF TRANSPORTATION DRAINAGE CONNECTION PERMIT To be completed by DOT Drainage Connection Pe No. 1 6 D 4 9 0 Received ByZc State Road No. Section No.�®(p Milepost 3 • you SCANNED BY °"SICN 1/� p /1 RO�A1O}Wgy pE 010 St• Lucie CoUlltvPege 1 or8 00 02 Date ,�55j1g�rb ,,/� Maintenance Unit `9 qo Work Program Project No. l ibi Construction Project No. Station Instructions for Drainage Connection Permit A(A Pursuant to 14-86.004(6), F.A.C. "The Drainage Connection Permit form serves as the application. Once approved by the Department, the form and supporting documents become the Drainage Connection Permit" The applicant shall submit four completed permit packages with original signatures. Each package shall include all required attachments. All required signed and sealed plans and supporting documentation shall be submitted on no larger than (11" X In multipurpose paper, unless larger plan sheets are requested by the reviewer. The package will include the following items. [fan item does not apply to your project, indicate "Not Applicable" or "WA." Included Part Title Completed b : Special Instructions 1 Permit Information Sheet Applicant 2 Certification by a Licensed Professional Licensed Professional Signed and Sealed 3 Certification Applicant Si nature 4 Ownees Authorization of a Representative Owner Signature 5 Affidavit of Ownership or Control and Statement of Contiguous Interest Owner Signature 6 Permit General Conditions FDOT 7 Permit Special Conditions FDOT 8 As -Built Certification Licensed Professional Signed and Sealed —Submit within 15 working days of completion of construction Attachment Legal Description Attachment Photographs of Existing Conditions Attachment Location Ma Attachment Grading Plan Licensed Professional Signed and Sealed Attachment Soil Bode s Attachment Water Table / Percolation Attachment Calculations Attachment CD with Electronic Files of all Submittal Items Scanned Images in pdf format Noie: Different Licensed Professionals may complete parts of the permit package. For example the Licensed Professional signing and sealing the as -built certification may be different from the Licensed Professional who signed and sealed the calculations for the permit package. EXCEPTIONS: Activities that qualify for an Exception are listed in Rule 14-86, F.A.C. A permit application to the Department is NOT required. However, if you desire verification whether the work qualifies for an exception, send a completed copy of this permit package with its requested information to the applicable FDOT District Office. 1.6D490 0002;`�` RULE 14-86.004, PAC. STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 850-04096 DRAINAGE CONNECTION PERMIT ROADWgY DESIGN Dw PeaazaO PART 1 - Permit Information Sheet Select one: ❑ Permit ® Exception Pursuant to 14-86.002(2), P.A.C. "Applicant means the owner of the adjacent property or the owner's authorized representative." Applicant Select one: ® Property Owner ❑ Owners Representative (Complete Part 4) Name: Nicholas Elliott Title and Company: Managing Member / Palm Park Center LLC Address: 8569 South USS Highway 1 City:gP.' �T LE�cli^ State: FL Zip: 34952 Telephone: 772-871-7900 FAX: 772-871-7950 Email: nickacoastaldeveloomentoorocom Property Owner (If not applicant) Name: same Tide and Company: Address: City. State: Zip: Telephone: FAX: Email: Applicant's Licensed Professional Name: Roderick J. Kennedy, PE Florida License Number: 56218 Title and Company: Engineering Design & Construction Inc (EDC) Address: 1934 Tucker Court City: Fort Pierce State: FL Zip: 34950 Telephone: 772-462-2455 FAX: 772-462-2454 Email: rodkennedygnedc-inc.com Project Information: Project Name: Coastal Floors and Granite - Location: 8532 South US Highway 1 5 1 Port St. Lucie STREET SR. NO. US HWY NO. CITY St. Lucie 26 36S 40E COUNTY SECTION(S) TOWNSHIP(S) RANGE(S) *Geographic Coordinates: Latitude (DMS.SSS): Longitude (DMS.SSS): Horikontal Datum: (NAD 83/_Adj.) *State Plane Coordinates: Northing Easting: Projection Zone: ❑ Florida North ❑ Florida East ❑ Florida West Coordinate shall be the center of the driveway intersection with FDOT R/W, or, if there is no driveway connection, near the center of the property line nearest the state highway. *Check with the FDOT Office for requirement. 1 6D490 0002 ,� RULE 14E .DX. FAG. STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 850 0 0-05 DRAINAGE CONNECTION PERMIT ROADWAYDESIGN 10/08 Page3are Brief description of facility and proposed connection: Project was previously permitted for drainage connection under permit no. 10D490 0014 on 12-22-2010 Proiect includes 1.25 acres of commercial development to include an 8,465 s.f. building, utilities, parking, and the associated stor mwater management system. Drainage will consist of a dry detention system with controlled discharge to an existing box culvert beneath US Highway 1 (State Road 5). Briefly describe why this activity requires a Drainage Connection Permit (Include where the stormwater will discharge to FDOT right of way): See above. The property abuts US Highway 1 (State Road 5) Stormwater will discharge onto the applicant's property and sheet flow to the existing box Gulvert beneath FDOT right-of-way. 1 6 D 4 9 0 0 0 0 Z RULE 14-86.004, FAC. STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 660-040-06 DRAINAGE CONNECTION PERMIT ROAOV AYDES�B Page 4 of 8 PART 2 — Certification by a Licensed Professional In accordance with Rule 14-86, Florida Administrative Code (F.A.C.), I hereby certify that the following requirements are and/or will be met. This project has been designed in compliance with all applicable water quality design standards as required by state governmental agencies. 14-86.004(3)(f) (F.A.C.): Certification by a Licensed Professional that the complete set of plans and computations complies with one of the following Rules Sections: ® 14-86.003(2)(a) (F.A.C.), or ❑ 14-86.003(2)(b) (F.A.C). (check one) I further certify that a National Pollutant Discharge Elimination System (NPDES) permit for stormwater discharges associated with industrial activity from construction sites ® is required ❑ is not required. (check one) I am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment This certification shall remain valid for any subsequent revision or submittal of plans, computation or other project documents by me. Name of Licensed Professional: Roderick J. Kennedy PE Florida License Number. Company Name (if applicable): Engineering Design & Construction, Inc. (EDC Certificate of Authorization Number (if applicable): CA 9935 Address: 1934 Tucker Court City: Fort Pierce State: FL Zip: 34950 Telephone: 772-462-2455 Fax: 772-462-2454 Email: rodkennedy(Medc-inc.com 160490 0002 RULE 1486.gp4, FAC. STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 85009005 DRAINAGE CONNECTION PERMIT Roaownv DEsWae Page5u(6 PART 3— Certification by Applicant 1 hereby certify that the inform�n t ' i is fete and accurate the est of my knowledge. Applicant's Signature: Date: ' y� Name (Printed): Nicholas Elliott Title and Company: Managing Member/ Palm Park Center LLC Address: 8569 South US Highway 1 Port St Lucie FL 34952 Phone Number: 772-871-7900 E-mail address: nick(o)coastaldeveloomentoorp com PART 4— Owner's Authorization of a Representative I (we), the owner, Nicholas Elliott Palm Park Center LLC do hereby authorize the following person, or entity, as my representative: Name (Printed): Roderick J. Kennedy PE Title and Company: Engineering Design & Construction Inc (EDC) Address: 1934 Tucker Court Fort Pierce, FL 34950 Phone Number: 772-462-2455 E-mail address: rodkennedv(a).edc-inc_com Part 5 —Affidavit of Property Ownership or Control and Statement of Contiguous Interest I, Nicholas ElliottPalm Park Center LLC certify that I own or lawfully control the following described property: 8532 South US Highway 1 Port St Lucie FL SLC PCN 3414-501-1903-200-7 Does the property owner own or have any interests in any adjacent property? ❑ No ® Yes If yes, please describe. Applicant is affiliated with property immediately south of proposed development (Parcel ID 3426-700-0001-000-3)' however he is not the owner or an authorized person(s). Owner's Signature required for Parts 4 andfor 5- We will not begin on the drainage connection until 1 receive the Permit and I understand all the conditions of the Permit. When work begins on the connection, I am accepting all conditions listed in the Permit. Name (Printed): Nicholas Elliott Address: 8569 South US Highway 1 Port St Lucie FL 34952 Phone Number. 772-871-7900 Signature: ZX Sj Date: It 1 6 D 4 9 0 0002 RULE 1a .004. FAC. STATE OF PLORIDADEPA EW OFi SPORTATION S50.0d0-0S DRAINAGE CONNECTION PERMIT ROADWAY DESMOB Page 6 of S PART 6 — Permit General Conditions 1. This permit is a license for permissive use only and does not convey any property rights either in real estate or material, or any exclusive privilege and it does not authorize any injury to private property or invasion of private rights, or any infringement of Federal, State or local laws, rules or regulations; nor does it obviate the necessity of obtaining any required state or local approvals. 2. The drainage connection as authorized herein shall be constructed and thereafter maintained in accordance with the documents attached hereto and incorporated by reference herein. 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. Such construction shall be subject to the inspection and approval of the Department, and the Department may at any time make such inspections as it deems necessary to assure that the drainage connection is in compliance with this permit. 3. The entire expense of construction within the Department right of way, including replacement of existing pavement or other existing features, shall be bome by the permittee. 4. The permittee shall maintain that portion of the drainage connection authorized herein located on permittee's property in good condition. The Department shall maintain that portion of the drainage connection authorized herein located within its right of way. 5. If the drainage connection is not constructed, operated or maintained in accordance with this permit, the permit may be suspended or revoked. In this event modification or removal of any portion of the drainage connection from the Department's right of way shall be at the permittee's expense. 6. The Department reserves the right to modify or remove the drainage connection to prevent damage or in conjunction with road improvements. 7. It is understood and agreed that the rights and privileges herein set out are granted only to the extent of the Department's right, title, and interest in the land to be entered upon and used by the permittee, and the permittee will, at all times, assume all risk of and indemnify, defend and save harmless the Department from and against any and all loss, damage, cost or expense arising in any manner on account of the exercise or attempted exercises by said permittee. of these rights and privileges, regardless of the respective degrees of fault of the parties. 8. Utilities, including gas lines, may exist within the right of way. Prior to beginning work the permittee shall contact Sunshine State One Call of Florida, Inc at 811 or 800-432-4770, who will notify all utility owners near the scheduled project. The utility owners have two (2) full business days to provide locations of their respective facilities. The permittee shall be solely responsible for any damage to or conflicts with gas lines, utilities and/or third persons. 9. The permittee siall notify the Department of Transportation Maintenance Office located at Phone r 7 %2 foo - �//f ai 48 hours in advance of starting any work on the drainage connection authorized b`y this permit and also 24 hours prior to any work within the Department's right of way. Construction of any work on the right of way shall be completed within days after such notification. If such construction is not completed within days after such notification, the permittee shall notify the Department of the anticipated completion date. 10. This permit shall expire if construction on the drainage connection is not begun within one year from the date of approval and if construction on the drainage connection is not completed by (Date) 11.. A permittee may request, an, extension of the Drainage Connection Permit expiration date by filing a written request for a permit time extension. All requests for time extensions must be received by the Department 15 working days prior to the expiration date. 12. All the provisions of this permit shall be binding on any assignee or successor in interest of the permittee. RULE 1"S.W4, FAC. STATE OF RORIDA DEPARrl.1ENr OF TRANSPORTATION DRAINAGE CONNECTION PERMIT PART 7 —Permit Special Conditions —To be completed by FDOT 8 0-0 ROADWAY DESIGN 1=8 Pe 7uF8 The above request has been reviewed and has been found to meet the regulations as prescribed in Rule 14-86, F.A.C., and is hereby approved, subject to the following special conditions: 16D-440-0002 There is an authorized sheetflow drainage connection to FDOT right of way. No structure is authorized. This Drainage Connection Permit does NOT authorize any work inside FDOT right of way. Any work inside FDOT right of way must be authorized by another -type of FDOT permit, such as an Access Permit. 16D-490-0002 Department of l Signature Title Drainage Designer Date February 23, 2016 RULE 1486.004, FAC. STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION &SD090Da DRAINAGE CONNECTION PERMIT ROADWAY DESIGN laoa Page 8 of 8 PART 8 — As -Built Certification Within 15 working days of completion of construction, you must send this certification to the Department office in which you filed your DOT Drainage Permit. 1. STORM WATER FACILITY INFORMATION Permit No.: source (Project) Name: Source Location: Street City: County: Source Owner. Owner Address: 2. AS -BUILT CERTIFICATION I hereby certify that this storm water facility has been built substantially in accordance with the certified design plans, and that any substantial deviations (noted below) will not prevent the facility from functioning in compliance with the requirements of Chapter 14-86 FA-C. when properly maintained and operated. These determinations have been based upon on -site observation of construction, scheduled and conducted by me or by a project representative under my direct supervision. Name of Licensed Professional: Florida License Number: Company Name (if applicable): Certificate of Authorization Number (if applicable): Address: City: Telephone: Fax: State: Email: Signature of Licensed Professional Date (Affix Seal) Substantial deviations from the approved plans and specifications (attach additional sheets if required). RULE 1466.U04, F.A.C. To be completed by DOT STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION DRAINAGE CONNECTION PERMIT Drainage Connection Pe No. 1 b D 4 9 0 Received By State Road No. Section No.olCB Milepost 3 • �dD C♦f. r,tJCre I "/n��. 650 40.06 St. LUGllb Aflo YDES� VU1�L� Pagel da 00 02 Date Maintenance Unit Work Program Project No. Construction Project No. Station Instructions for Drainage Connection Permit Pursuant to 14-86.004(6), F.A.C. "The Drainage Connection Permit form serves as the application. Once approved by the Department, the form and supporting documents become the Drainage Connection Permit" The applicant shall submit four completed permit packages with original signatures. Each package shall include all required attachments. All required signed and sealed plans and supporting documentation shall be submitted on no larger than (11" X 17") multipurpose paper, unless larger plan sheets are requested by the reviewer. The package will include the following items. If an item does not apply to your project, indicate "Not Applicable" or "N/A." Included Part Title Completed by: Special Instructions 1 Permit Information Sheet Applicant 2 Certification by a Licensed Professional Licensed Professional Signed and Sealed 3 Certification Applicant Signature 4 Owner's Authorization of a Representative Owner Signature 5 Affidavit of Ownership or Control and Statement of Contiguous Interest Owner Signature 6 Permit General Conditions FDOT 7 Permit Special Conditions FOOT 8 As -Built Certification Licensed Professional Signed and Sealed — Submit within 15 working days of completion of construction Attachment Legal Description Attachment Photographs of Existing Conditions Attachment Location Ma Attachment Grading Plan Licensed Professional Signed and Sealed Attachment Soil Borings; Attachment Water Table / Percolation Attachment Calculations Attachment CD with Electronic Files of all Submittal Items Scanned Images in pdf format Note: Different Licensed Professionals may complete parts of the permit package. For example the Licensed Professional signing and sealing the as -built certification may be different from the Licensed Professional who signed and sealed the calculations for the permit package. EXCEPTIONS: Activities that qualify for an Exception are listed in Rule 14-86, F.A.C. A permit application to the Department is NOT required. However, if you desire verification whether the work qualifies for an exception, send a completed copy of this permit package with its requested information to the applicable FDOT District Office. 1.6D490 00021 RULE 14ffi.M4, F.A.C. STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION DRAINAGE CONNECTION PERMIT 950046 ROADWAY DESIGN 1010 Pa 2ae PART 1 — Permit Information Sheet Select one: ❑ Permit ® Exception Pursuant to 14-86.002(2), F.A.C. "Applicant means the owner of the adjacent property or the owner's authorized representative." Applicant Select one: ® Property Owner ❑ Owner's Representative (Complete Part 4) Name: Nicholas Elliott Title and Company: Managing Member t Palm Park Center LLC Address: 8569 South US Highway 1 City: APPT 5;1 2-tro-14 State: FL Zip: 34952 Telephone: 772-871-7900 FAX: 772-871-7950 Email: nickc&coastaldevelocmentcorocom Property Owner (If not applicant) Name: same Title and Company: Address: City: State: Zip: Telephone: FAX: Email: Applicants Licensed Professional Name: Roderick J. Kennedy PE Florida License Number: 56218 Title and Company: Engineering Design & Construction, Inc (EDC) Address: 1934 Tucker Court City: Fort Pierce State: FL Zip: 34950 Telephone: 772-462-2455 FAX: 772-462-2454 Email: rodkennedv(g�edc-mc.com Project Information: Project Name: Coastal Floors and Granite Location: 8532 South US Highway 1 5 1 Port St Lucie STREET SR. NO. US HWY NO. CITY St. Lucie 26 36S 40E COUNTY SECTION(S) TOWNSHIPS) RANGE(S) *Geographic Coordinates: Latitude (DMS.SSS): Longitude (DMS.SSS): Horizontal Datum: (NAD 831_Adj.) * State Plane Coordinates: Northing Easting: Projection Zone: ❑ Florida North ❑ Florida East ❑ Florida West Coordinate shall be the center of the driveway intersection with FDOT RIK or, if there is no driveway connection, near the center of the property line nearest the state highway. *Check with the FDOT Office for requiremenL 1 60490 0002 RULE 1486.004. FAG. STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 8502W0418 DRAINAGE CONNECTION PERMIT ROADWAYDESIGN 10108 Pege 3 d 8 Brief description of facility and proposed connection: Proiect was previously permitted for drainage connection under permit no. 1 OD490 0014 on 12-22-2010 Proiect includes 1.25 acres of commercial development to include an 8,465 s.f. building. utilities parking, and the associated stormwater management system. Drainage will consist of a dry detention system with controlled discharge to an existing box culvert beneath US Highway 1 (State Road 5) Briefly describe why this activity requires a Drainage Connection Permit (Include where the stormwater will discharge to FDOT right of way): See above. The property abuts US Highway 1 (State Road 5). Stormwater will discharge onto the applicants property and sheet flow to the existing box culvert beneath FDOT right-of-way. 1 6 D 4 9 0 0002 RULE 1488-A ., FAC. STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION &5D-D4DU8 DRAINAGE CONNECTION PERMIT ROADWAYDESIGN 10108 Page 4 of 0 PART 2— Certification by a Licensed Professional In accordance with Rule 14-86, Florida Administrative Code (F.A.C.), I hereby certify that the following requirements are and/or will be met. This project has been designed in compliance with all applicable water quality design standards as required by state governmental agencies. 14-86.004(3)(f) (F.A.C.): Certification by a Licensed Professional that the complete set of plans and computations complies with one of the following Rules Sections: ® 14-86.003(2)(a) (F.A.C.), or ❑ 14-86.003(2)(b) (F.A.C). (check one) I further certify that a National Pollutant Discharge Elimination System (NPDES) permit for stormwater discharges associated with industrial activity from construction sites ® is required ❑ is not required. (check one) I am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment This certification shall remain valid for any subsequent revision or submittal of plans, computation or other project documents by me. Name of Licensed Professional: Roderick J. Kennedy, PE Florida License Number. 56218 Company Name (if applicable): Engineering Design & Construction Inc (EDC) Certificate of Authorization Number (if applicable): CA 9935 Address: 1934 Tucker Court City: Fort Pierce State: FL Zip: 34950 Telephone: 772-462-2455 Fax: 772-462-2454 Email: rodkennedvCrDedc-inc.com 16D490 0002 RULE 14.W.OD4, FAC. STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 850` '040-M DRAINAGE CONNECTION PERMIT ROADWAYDESIGN Page 5 v(S PART 3 — Certification by Applicant hereby certify that the inform �n t� i is fete and accurate the est of my knowledge. Applicant's Signature: Date: 24 Ilk Name (Printed): Nicholas Elliott Title and Company: Managing Member/ Palm Park Center LLC Address: 8569 South US Highwav 1 Port St Lucie FL 34952 Phone Number: 772-871-7900 E-mail address: nick0coastaldevelopmentcorp cam PART 4— Owner's Authorization of a Representative l (we), the owner, Nicholas Elliott Palm Park Center LLC do hereby authorize the following person, or entity, as my representative: Name (Printed): Roderick J. Kennedy PE Title and Company: Engineering Design & Construction Inc (EDC) Address: 1934 Tucker Court Fort Pierce, FL 34950 Phone Number. 772-462-2455 E-mail address: rodkennedV(c edc-inc.com Part 5 —Affidavit of Property Ownership or Control and Statement of Contiguous Interest I, Nicholas ElliottPalm Park Center LLC , certify that I own or lawfully control the following described property: 8532 South US Highwav 1 Port St Lucie FL SLC PCN 3414-501-1903-200-7 Does the property owner own or have any interests in any adjacent property? ❑ No ® Yes If yes, please describe. Applicant is affiliated with property immediately south of proposed development (Parcel ID 3426-700-0001-000-3); however he is not the owner or an authorized person(s). Owner's Signature required for Parts 4 and/or 5 We will not begin on the drainage connection until 1 receive the Permit and I understand all the conditions of the Permit. When work begins on the connection, I am accepting all conditions listed in the Permit. Name (Printed): Nicholas Elliott Address: 8569 South US Highway 1 Port St Lucie FL 34952 Phone Number. 77M71-7900 Signature: Date: g 1 6 D 4 9 0 0002 RULE 14.86.OD4, F.AC. STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION B5P040-0 DRAINAGE CONNECTION PERMIT ROADWAVDESIIGGN Pa9a 6 of 8 PART 6 - Permit General Conditions 1. This permit is a license for permissive use only and does not convey any property rights either in real estate or material, or any exclusive privilege and it does not authorize any injury to private property or invasion of private rights, or any infringement of Federal, State or local laws, rules or regulations; nor does it obviate the necessity of obtaining any required state or local approvals. 2. The drainage connection as authorized herein shall be constructed and thereafter maintained in accordance with the documents attached hereto and incorporated by reference herein. 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. Such construction shall be subject to the inspection and approval of the Department, and the Department may at any time make such inspections as it deems necessary to assure that the drainage connection is in compliance with this permit. 3. The entire expense of construction within the Department right of way, including replacement of existing pavement or other existing features, shall be borne by the permittee. 4. The permittee shall maintain that portion of the drainage connection authorized herein located on permittee's property in good condition. The Department shall maintain that portion of the drainage connection authorized herein located within its right of way. 5. If the drainage connection is not constructed, operated or maintained in accordance with this permit, the permit may be suspended or revoked. In this event modification or removal of any portion of the drainage connection from the Department's right of way shall be at the permittee's expense. 6. The Department reserves the right to modify or remove the drainage connection to prevent damage or in conjunction with road improvements. 7. It is understood and agreed that the rights and privileges herein set out are granted only to the extent of the Department's right, title, and interest in the land to be entered upon and used by the permittee, and the permittee will, at all times, assume all risk of and indemnify, defend and save harmless the Department from and against any and all loss, damage, cost or expense arising in any manner on account of the exercise or attempted exercises by said permittee. of these rights and privileges, regardless of the respective degrees of fault of the parties. 8. Utilities, including gas lines, may exist within the right of way. Prior to beginning work the permittee shall contact Sunshine State One Call of Florida, Inc at 811 or 800-432-4770, who will notify all utility owners near the scheduled project. The utility owners have two (2) full business days to provide locations of their respective facilities. The permittee shall be solely responsible for any damage to or conflicts with gas lines, utilities and/or third persons. 9. The permp - sh II notify the Department of Transportation Maintenance Office located at �oNri rr1l.�J+� Phone ( 17A <-i &0 - -7//19 48 hours in advance of starting any work on the drainage connection authorized by this permit and also 24 hours prior to any work within the Department's right of way. Construction of any work on the right of way shall be completed within days after such notification. If such construction is not completed within days after such notification, the permittee shall notify the Department of the anticipated completion date. 10. This permit shall expire if construction on the drainage connection is not begun within one year from the date of approval and if construction on the drainage connection is not completed by (Date) 2. `� _ FE- 8 -204- 11.. A permittee .may request.an, extension ofthe Drainage Connection .P rmit.expiration date by filing a written request. for a permit time extension. All requests for time extensions must be received by the Department 15 working days prior to the expiration date. 12. All the provisions of this permit shall be binding on any assignee or successor in interest of the permittee. RULE 14 ,IX)4, FAG STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 850.616LB DRAINAGE CONNECTION PERMIT ROAOWAYDESIGN 1N Page ] of 8 PART 7 —Permit Special Conditions —To be completed by FDOT The above request has been reviewed and has been found to meet the regulations as prescribed in Rule 14-86, F.A.C., and is hereby approved, subject to the following special conditions: 16D-490-0002 There is an authorized sheetflow drainage connection to FDOT right of way. No structure is authorized. This Drainage Connection Permit does NOT authorize any work inside FDOT right of way. Any work inside FDOT right of way must be authorized by another type of FDOT permit, such as an Access Permit. 16D-490-0002 Department of T Signature Tale Drainage Designer Date February 23, 2016 RULE 1486,004. FAC. STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION DRAINAGE CONNECTION PERMIT 8 aso-04o•08 ROADWAY DESIGN flame Page 8 of 8 Within 15 working days of completion of construction, you must send this certification to the Department office in which you filed your DOT Drainage Permit. Permit No.: Source (Project) Name: Source Location: Street City: Source Owner. Owner Address: 1. STORM WATER FACILITY INFORMATION 1 6 D 4 9 0 0002 2. AS -BUILT CERTIFICATION I hereby certify that this storm water facility has been built substantially in accordance with the certified design plans, and that any substantial deviations (noted below) will not prevent the facility from functioning in compliance with the requirements of Chapter 14-86 F.A.C. when properly maintained and operated. These determinations have been based upon on -site observation of construction, scheduled and conducted by me or by a project representative under my direct supervision. Name of Licensed Professional: Florida License Number: Company Name (if applicable): Certificate of Authorization Number (if applicable): Address: City: Telephone: Fax: State: Email: Zip: Signature of Licensed Professional Date (Affix Seal) Substantial deviations from the approved plans and specifications (attach additional sheets if required).