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• 4 <br /> i <br /> STATE OF FLORIDADEPAmMENx OF7RA &eMTAnO?4 85D-W16 *, ( <br /> DRIVEWAY/CONNECTION APPLICATION SYSMSPLANNWe <br /> FOR ALL CATEGOMS a0± <br /> Page 1 ot3 <br /> OFFICE USE ONLY <br /> Application Number. Received By: <br /> Category: TDate: <br /> FDOT SfAr-F(ryPEOFtPwNT) i. <br /> /� 3 ! - 7 <br /> Section/Mile Post: , ^ �/ /V(,e4 / j 2 3 State Road: <br /> ' i <br /> Section/Mile Post: State Road:' <br /> Instructions - To Applicant <br /> e <br /> • Contact the Department ofTransportation to determine what plans and other documents you are required to submit emir <br /> with your applicatipy > <br /> • Complete this form (some questions may not apply to you) and attach all necessary documents and submit it to the Department of <br /> Transportation. <br /> • For help with thts forth contact your local Maintenance or District Office. <br /> • Or visit our website at http:/Mml .mygofida .com/onestoppermMting/ fcr the contact person and phone number in your area GC <br /> • You may also email - drtvewaysQDdot.state.fl.us <br /> • Or call your District or local Florida Department of Transportation Office and ask for Driveway Permits. <br /> Please print ortype <br /> APPLICANT: Ilk5 N-- i <br /> Check one: <br /> 0 Ow ler 0 Lesser 0 Contract to Purchase it <br /> Name: Indian River County Rog rd of C'rnnnt' y Cnmmi aci nna <br /> Responsible Officer or Person: ZhrIZtOlpher jr - Kaferr, jr -0 . 1, _ <br /> If the Applicant is a Company or Organization, Name: - <br /> r <br /> Address: 1840 25th Street <br /> City, State: 3LPrn RPaCih r F7 nri ria z <br /> Zip: 3 2 9 60 Phone: 772 - 567 - 8000 Fax: <br /> 7ZZ2- 7Zg 939 ' t <br /> Email: ckafer(dircgoy . com <br /> I <br /> l <br /> E <br /> LANDOWNER: (if not applicant) <br /> i <br /> Name: <br /> If the Applicant is a Company or Organization, Name: <br /> Address: <br /> City, State: <br /> l <br /> Zip: Phone: Fax : IL <br /> Email: <br /> f <br /> y <br /> Z <br /> P iQ <br /> RECEIVED <br /> J' MAR 0 6 2007 <br /> � U r DISTH M PERMITS ' <br /> i <br />