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RULE 14-86.DD4, F.A.C. STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION BSD -0404)6 <br />DRAINAGE CONNECTION PERMIT ROADWAYDESKaN <br />1 oroB <br />Page 8 of 8 <br />PART 8 — As -Built Certification <br />Within 15 working days of completion of construction, you must send this certification to the Department office in which <br />you filed your DOT Drainage Permit. <br />1. STORM WATER FACILITY INFORMATION <br />B�iMON <br />Source (Project) Name: <br />Source Location: Street <br />City: County: <br />Source Owner. <br />Owner Address: <br />2. AS -BUILT CERTIFICATION <br />I hereby certify that this storm water facility has been built substantially in accordance with the certified design plans, and <br />that any substantial deviations (noted below) will not prevent the facility from functioning in compliance with the <br />requirements of Chapter 14-86 F.A.C. when properly maintained and operated. These determinations have been based <br />upon on-site observation of construction, scheduled and conducted by me or by a project representative under my direct <br />supervision. <br />Name of Licensed Professional: <br />Florida License Number. <br />Company Name (if applicable): <br />Certificate of Authorization Number (if applicable): <br />Address: <br />City: <br />Telephone: <br />Fax: <br />State: <br />Email: <br />Zip: <br />Signature of Licensed Professional <br />Date <br />(Affix Seal) <br />Substantial deviations from the approved plans and specifications (attach additional sheets if required). <br />Georgi Celusnek <br />5/1/2.018 <br />