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1. <br />aAPPLICATION FOR A PERMIT FOR CONSTRUCTION <br />rtoR A "" SEAWARD OF THE COASTAL CONSTRUCTION <br />CONTROL LINE OR FIFTY -FOOT SETBACK <br />Owner of Record <br />Agent (if applicable) <br />Anted Name <br />Printed Name / <br />Indian River Count <br />M <br />Meiling Address <br />Melling Add.... <br />1840 25th Street <br />Cly <br />city <br />Siete <br />ap codCity <br />I <br />state <br />ZIPCode <br />Vero Beach <br />FL <br />I 32960 <br />TN+Phone <br />561 567-8000 <br />FAX <br />561 770-5403 <br />T.I.phane <br />FAX <br />2. 1 hereby certiWhaat LtnfaTmatton submltted with this application Is true and complete to the best of my knowledge. <br />6G Jeffre r�R. Taber. P.E. <br />t e o Applicant to Typed or printed name of applicant, also title of person signing H representing a <br />il�corporation or other business entity, and the name of that entity. <br />3. If the applicant Is not the owner of record, the owner must authorize the applicant to act as the owner's agent for the purpose <br />of applying for a permit, and to act on behalf of the owner In other matters pertaining to this permit by signing below. <br />I hereby authorize /VZ/ / to make <br />application for a permit for conslntction or other activities seaward of the cg6stal construction control line or 50• foot setback on the property <br />described In item #6, and to act In my behalf in other matters pertaining to the permit. <br />4, <br />5. <br />Signature of Owner Dale Typed or printed name of owner, also title of person signing if representing a <br />A brief description of the proposed work, activity, or construction. <br />Installation of approximately 9000 linear feet of protective sand berm at eight (8) separate <br />sites along Indian River County. Sand will be obtained from clean upland source. <br />Cheok hart It sddlflonei Information le snsohed. <br />P.Ject Nam. (for m.104 -11y, commHc1.1 or pu011a prof.ct.) 1 <br />Nearest DEP Reference Manument(s), It known <br />Indian River Countv Sand Berm/Dune Restoration Proiect <br />R-12 to R-107 <br />steal Address <br />Cly <br />Count' <br />ap Coda <br />US Highway A1A <br />I <br />Intl. River <br />32963 <br />I <br />The name and mailing address of the owners of the Immediately adjacent properties, exclusive of street ends and easements. <br />If the adjacent property Is under cooperative or condominium ownership, the name and mailing address of the cooperative <br />association will suffice. <br />He—or AdJ.c.nt Prop.ry (Teter <br />Nam. at Adjacent Property awns <br />N � <br />N <br />Ing r... <br />a np r... <br />Cityalai. <br />ap eoa. <br />City <br />stet. <br />ZIP ori. <br />Cheek her If Mn. iin,dltl eeledliggeet yg,P,nI,,h rf l informedon. <br />DEP Form 73.100 (Rev. 5198) Page 1 of 2 Agency Use Only: FILE NUMBER: <br />