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AUTHORIZED REPRESENTATIVE If specified by Applicant to handle., represent. sign and file the application - <br />NOTE A notarized letter of authoftaffon must be provided m* the-Applic9lion <br />Name: N/A <br />Company Name; <br />Address: <br />C4, State: <br />Phone: Rm <br />Email: <br />Address of property to be served by permit Cif known): <br />If addiess Is not knoWn provide distance from pearea-interse6ting public street {such as 500 The south of Win St <br />Intersection of SR60 and 43rd Avenue, east to Atlantic Blvd. <br />Check Frere lf you are reques" a <br />0 newdriveway 0 -temporary driviwmy §D modification to e"ng driveway 0 safety upgrade <br />Does the pnaperly, owner own or have any interests in any a6jac*bt pmpW- <br />0 No OYes ifyes-pteasedescme- NE extension of Atlantic Blvd. eastof 42nd Avenue <br />[Are <br />there otheir e9sting or dedicated public streets, mads, highways or access easements bordering or -within the property,? <br />OND ,W Yes ffyes -lisilhern on hour plans and 40ML- the proposed and wasti . N access points <br />or Approval. Informatiort. <br />c7ownrmntcontact - Indian -lRiVer-C <br />oUnty'.Public Works-- <br />Awncw, Indian RiverCounty <br />. 7727226-1221 <br />RM -040-115 <br />SYSTEMS PLAWNG <br />.040. <br />Page 2 of:3 <br />Approved <br />2018-A-490-01 0 <br />Na Harden <br />..5/812C1I18 <br />