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RULE 14-86.004,FAC. STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 85-0404M <br />DRAINAGE CONNECTION PERMIT RoADwAYDEIMS <br />Pages of.8% <br />PART 3 — Certification by Applicant <br />I hereby certify that the information in this. submittal is complete and accurate to the best of my knowledge. <br />Applicantsignature.)( Z f Date: 1ZT Item + <br />.Mame (Printed);. Mr: Ja s Ennis <br />r Title and Company: County Engineer indian .River County <br />Address, 1601 271h Streets Vero Beach- FL 32960 <br />Phone Number 772226-1221 E -Mail address: <br />PART 4 - Owner's Authorization. of a Representative <br />I (we), the owner, City of Vero Beach PubligWorks - Mr. Matthew Mitts., do hereby authorize the following person, or <br />entity, as my representative: <br />Name (Printed): Mr. James Ennis <br />Title and, Company: County Engineer - Indian River.County <br />Address: 180127"1" Street: Vero Beach 'FL 32960 <br />Phone Number 772226-1221 E-mail address: lanniso-4egov.com <br />a — Affidavit of <br />Or Control and Statement of <br />t, Matthew Mitts, City Engineer (city of Vero Beach) , certify that 1 own or lawfully control the following <br />described property: extension of Atlantic Blvd. <br />Does. the. property .owner own or have any interests in any adjacent property? <br />[� No 19 Yes if yes; please describe.. Extension of 42m Avenue (Atlantic Blvd,) tc <br />Owner's <br />Parts 4 <br />We will not begin on the drainage connection until I receive the Perm&and l understand. all. the conditions of the Permit. <br />When work begins on the:connection; I an aocepting all conditions listed in the Permit. <br />Name (Printed) Mr. James Ennis <br />Address: 1.801 27th Street: Vero Beach; "FL 32.9.60 <br />Phone Number. 772 6-1 <br />Signature <br />Date: 12/I5/y014 <br />Approved . <br />2018-D-490-005 <br />Georgi Celusnek <br />5/1/2018 <br />