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66ppgPi6 <br /> 5YMMS PLANMXG <br /> Page 2d3 <br /> AUTHORIZED REPRESENTATIVE: If specified by Applicant to handle, represent, sign, and file the application - <br /> NOTE: A notarized letter of authorization must be provided with the Application <br /> Name: <br /> Company Name: <br /> w <br /> Address: <br /> City, State: <br /> 110 <br /> Zip: Phone: Fax: <br /> Email: <br /> No <br /> Address of property to be served by permit at known): <br /> l• If address is not known provide distance from nearest intersecting g public street (such as, 500 feet south of Main St.) <br /> 375 feet east of intersection of I - 95 & CR 512 <br /> Check here if you are requesting a <br /> Q newdriveway O temporary driveway O modification to existing driveway safety upgrade <br /> Does the property owner own or have any interests in any adjacent property? <br /> a No 0 Yes, if yes - please describe: <br /> Are there other existing or dedicated public streets, roads, highways oraccess easements bordering or within the property? <br /> Q No Q Yes, if yes - list them on your plans and indicate the proposed and existing access points. <br /> Local Government Development Review or Approval lnfonnation: <br /> Local Government Contact: Christopher T Kafarr. T r P 7 <br /> Name: <br /> Government Agency: Indian EJVPY <br /> 40 Phone * 772 - 567 - 8000 <br /> tr <br /> r <br /> MAR ® 6 2007 <br /> I. <br />