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Home My Public Portal About2012 Miami-Dade Class I Permit Application.tifMIAMI-DiADE COUNTY Class I Permit Application ,_w._ , POIWDEP1 MEAL JAE:ONLY.• ti 4P]PliOtion Feet - Application must be filled out in its entirety. Please indicate N/A for non -applicable fields. 1. Applicant Information: Name• Village of Key Biscayne Address: 88 West McIntyre Street Key Biscayne, Florida Zip Code: 33149 Phone #:(305) 365-8945 Fax#: (305) 365-7757 Email: jgilbert@keybiscayne.fl.gov * This should be the applicant's information for contact purposes. 2. Applicant's Authorized Permit Agent: Agent is allowed to process the application, furnish supplemental information /elating to the application and bind the applicant to all requirements of the application. Name: Daniel Moretz-Coastal Systems International Inc. Address: 2047 Vista Parkway West Palm Beach Florida Zip Code: 33411 Phone #: (561) 478-1002 x3fi Fax #: (561) 640-1009 Email: dmoretz@coastalsystemsint.com 3. Location where proposed activity exists or will occur (latitude and longitude are only necessary for properties without address or folio #): Folio #(s): N/A Street Address: 400 Harbor Drive to 500 Bay Lane In City or Town: Village of Key Biscayne Name of waterway at location of the activity: Biscayne Bay Latitude: 25° 41' 39.02" Section: 5, 6 Longitude: 80° 10' 24.97" Township: 55 Range:42 Near City or Town: 4. Describe the proposed activity (check all that apply): O Seawall ❑ New/Replacement Seawall ❑ Seawall Cap O Batter Piles ❑ King Piles O FooterlToe Wall ❑ Riprap ❑ Dock(s) ❑ Pier(s) ❑ Viewing Platform ❑ Boatlift ❑ Mooring Piles ❑ Fender Piles ❑ Davits O Dredging ❑ Maintenance ❑ New ❑ Filling t3 Other: The installation of four (4) floating vessel exclusion/swim area buoys. Estimated project cost = $$11,400 Are you seeking an after -the -fact approval (ATF)? O Mangrove Trimming O Mangrove Removal DYes )gNo If "Yes", describe the ATF work: 5. Proposed Use (check all that apply):, O Single Family O Multi -Family ❑ Private g Public O Commercial ❑ Industrial ❑ Utility 6. If the proposed work relates to the mooring of vessels provide the following information (please also indicate if the applicant does not have a vessel): Proposed Vessel Type (s): N/A Vessel Make/Model (If known): N/A Draft (s)(range in inches.): N/A Length (s)(range in feet.): N/A Total Number of Slips: N/A 7. List all permits or certifications that have been applied for or obtained for the above referenced work: Issuing Agency Type of Approval Identification Number Corps NW -1 TBD DEP Exemption TBD FWC FUWM TBD Application Date March 8,2012 March 8, 2012 March 8,2012 Approval Date Pending Pending Pending 1 Revised 'I/1o19 8. Contractor Information (If known): Name: TBD License # (County/State): Address: Zip Code: Phone #: Fax #: E-mail: 9. IMPORTANT NOTICE TO APPLICANTS: The written consent of the property owner is required for all applications to be considered complete. Your application WILL NOT BE PROCESSED unless the Applicant and Owner Consent portion of the application is completed below. You have the obligation to apprise the Department of any changes to information provided in this application. Application is hereby made for a Miami -Dade County Class I permit to authorize the activities described herein. I agree to or affirm the following: • I possess the authority to authorize the proposed activities at the subject property, and • I am familiar with the information, data and plans contained in this application, and • To the best of my knowledge and belief, the information, data and plans submitted are true, complete and accurate, and • I will provide any additional information, evidence or data necessary to provide reasonable assurance that the proposed project will comply with the applicable State and County water quality standards both during construction and after the project is completed, and • I am authorizing the permit agent listed in Section 2 of this application to process the application, furnish supplemental information relating to this application and bind the applicant to all requirements of this application, and • I agree to provide access and allow entry to the project site to inspectors and authorized representatives of Miami -Dade County for the purpose of making the preliminary analyses of the site and to monitor permitted activities and adherence to all permit conditions. A. IF APPLICANT IS AN INDIVIDUAL Signature of Applicant Print Applicant's Name Date B. IF APPLICANT IS OTHER THAN AN INDIVIDUAL OR NATURAL PERSON (Examples: Corporation, Partnership, Trust, LLC, LLP, etc.) Village of Key Biscayne Government Print Name of Applicant (Enter the complete name as registered) Registration/Incorporation Florida Type (Corp, LLC, LLP, etc.) State of Under the penalty of perjury, I certify that I have the authority to sign this application on behalf of the Applicant, to bind the Applicant, and if so required to authorize the issuance of a bond on behalf of the Applicant. (If asked, you must provide proof of such authority to the Department). ***Please Note: If additional signatures are reouired,oursuant to your_governing documents, operating agreements, or o er applicable agreements or laws, You must attach additional signature pages. *** --John C. Gilbert nature of Authoriz Representative Print Authorized Representative's Name F APPLICANT IS A JOINT VENTURE Each party must sign below(If more than two members, list on attached page) Print Name of Applicant (Enter the complete name as registered) Registration/incorporation Type (Corp, LLC, LLP, etc.) State of Print Name of Applicant (Eater the complete name as registered) Registration/lncorporation Type (Corp, LLC, LLP, etc.) State of Under the penalty of perjury, I certify that I have the authority to sign this application on behalf of the Applicant, to bind the Applicant, and if so required to authorize the issuance of a bond on behalf of the Applicant. (If asked, you must provide proof of such authority to the Department). ***Please Note: If additional signatures are required, pursuant to your governing documents, operating agreements, or other applicable agreements or laws, you must at : ch additional signature pages. *** Signature of Authorized Representative Print Authorized Representative's Name Title Date Signature of Authorized Representative Print Authorized Representative's Name Title Date 2 Revised 11/16/09 10. WRITTEN CONSENT OF THE PROPERTY OWNER OF THE AREA OF THE PROPOSED WORK I/We are the fee simple owner(s) of the real property located at _ Miami -Dade County, Florida, otherwise identified in the public records of Miami -Dade County as Folio No. I am aware and familiar with the contents of this application for a Miami -Dade County Class 1 Permit to perform the work on or adjacent to the subject property, as described in Section 4 of this application. I possess the riparian rights to the area of the proposed work (if applicable) and hereby consent to the work identified in this Class I Permit application. A. IF THE OWNER(S) IS AN INDIVIDUAL Signature of Owner Signature of Owner Print Owner's Name Date Print Owner's Name Date B. IF THE OWNER IS OTHER THAN AN INDIVIDUAL OR NATURAL PERSON (Examples: Corporation, Partnership, Joint Venture, Trust, LLC, LLP, etc.) Print Name of Owner (Enter the complete name as registered) Type (Corp, LLC, LLP, etc.) State of Registration/Incorporation Address of Owner Under the penalty of perjury, I certify that I have the authority to sign this application on behalf of the Owner, to bind the Owner, and if so required to authorize the issuance of a bond on behalf of the Owner. (If asked, you must provide proof of such authority to the Department). ***Please Note: If additional signatures are required, pursuant to your governing documents. operating agreements, or other applicable agreements or laws, von must attach additional si nature pages. *** Signature of Authorized Representative Print Authorized Representative's Name Title Date Signature of Authorized Representative Print Authorized Representative's Name Title Date Please Review Above Appropriate signature(s) must be included in: Box 9: either A, B or C AND Box 10: either A or B 3 Revised II/16/09 Class I Permit Application Additional Signatures Page (Please attach to Class 1 permit application) Applicant Name: Owner Name: Project Location: Additional signatures for: Village of Key Biscayne Board of Trustees of the Internal Improvement Trust Fund Biscayne Bay Aquatic Preserve adjacent to 400 Harbor Drive to 500 Bay Lane 0 Applicant 0 Owner X Adjacent Upland Owners 1. IF THE APPLICANT/OWNER IS AN INDIVIDUAL Signature of Applicant/Owner Signature of Applicant/Owner Print Name of Applicant/Owner Print Name of Applicant/Owner 2. IF THE APPLICANT/OWNER LS OTHER THAN AN INDIVIDUAL OR NATURAL PERSON (Examples: Corporation, Partnership, Trust, LLC, LLP, etc.) Date Date Print Name of Applicant/Owner (Enter the complete name as registered) Type (Corp, LLC, LLP, etc.) State of Registration/Incorporation Under the penalty of perjury, we certify that we have the authority to sign this application on behalf of the Applicant/Owner, to bind the Applicant/Owner, and if so required to authorize the issuance of a bond on behalf of the Applicant/Owner. (If asked, you must provide proof of such authority to the Department). ***Please Note: If additional signatures are required, pursuant to your governing documents, operating agreements, or other applicable agreements or laws, You must attach additional signature pages. *** Signature Print Name Title Date Signature Print Name Title Date Signature Print Name Title Date Signature Print Name Title Date Signature Print Name Title Date Signature Print Name Title Date Signature Print Name Title Date Signature Print Name Title Date Signature Print Name Tide Date 4 Revised 11/16/09