CITY OF PALM BEACH GARDENS UTILITIES EASEMENT …
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CITY OF PALM BEACH GARDENS UTILITIES EASEMENT AGREEMENT To Whom It May Concern: I propose to apply for a building permit to erect a __________________________________________________ in the utility (Description of proposed improvement) easement on my property at ___________________________________________________________, the legal description of (Property Address) the property being shown on the attached survey. A brief description of dimensions and location from property line, etc., follows: ___________________________________________________________________________________________. In the event that you have no objection to this project, please complete this form and return it to me at ____________________________, or mail to above address. (Applicant’s Fax Number) I understand that your company will not be held responsible in any way for repairs or replacement of the above noted improvements, and that any removal or replacement of these improvements necessary to allow use of this easement will be done at my expense. Owner’s Signature:____________________________________ Print Name: _____________________________________ STATE OF FLORIDA COUNTY OF ______________________________________________ The foregoing instrument was acknowledged before me this ______________ day of _________________________, 20_____ by __________________________________________________________________. (Name of person acknowledging) (Print, type or stamp Commissioned Name of Notary Public) _____________________________________________________________ (Signature of Notary Public) Personally known ___________ OR Produced Identification____________ Type of Identification__________________________________ ------------------------------------------------------------------------------------------------------------------------------------------------------------------ PLEASE FAX THIS FORM ALONG WITH A COPY OF YOUR PROPOSED SITE PLAN TO EACH OF THE AGENCIES LISTED BELOW (SELECT ONLY ONE AGENCY PER FORM). PLEASE ENSURE YOU HAVE PROVIDED A RETURN FAX NUMBER. YOUR REQUEST WILL BE PROCESSED IN THE ORDER IT IS RECEIVED BY THE UTILITY AGENCY. PLEASE ALLOW SUFFICIENT PROCESSING TIME BEFORE YOU CONTACT THE UTILITY AGENCY WITH QUESTIONS. Agency Fax Number/E-mail Questions Florida Power & Light 561-575-6333 [email protected] Seacoast Utility Authority 561-624-2839 AT&T Comcast Cable g44448@att.com 561-454-5899 / [email protected] TECO Peoples Gas System 561-741-4028 / [email protected] 561-616-1601 561-627-2900 ext. 1462 305-222-8248 561-815-6659 813-275-3783 561-624-7830 We agree to the proposed construction under the circumstances described above. ________________________________________________________________________ ___________________________ (Utility Agency Signature) (Title) _________________________________________________________________________ __________________________ (Print Name) (Date) Select one agency only per form and indicate selection by a check mark REV 02/16/22 NPBCID 561-624-7839 / [email protected]
Transcript of CITY OF PALM BEACH GARDENS UTILITIES EASEMENT …
CITY OF PALM BEACH GARDENS UTILITIES EASEMENT AGREEMENT
To Whom It May Concern: I propose to apply for a building permit to erect a __________________________________________________ in the utility
(Description of proposed improvement) easement on my property at ___________________________________________________________, the legal description of
(Property Address) the property being shown on the attached survey. A brief description of dimensions and location from property line, etc.,
follows: ___________________________________________________________________________________________.
In the event that you have no objection to this project, please complete this form and return it to me at ____________________________, or mail to above address. (Applicant’s Fax Number)
I understand that your company will not be held responsible in any way for repairs or replacement of the above noted improvements, and that any removal or replacement of these improvements necessary to allow use of this easement will be done at my expense.
Owner’s Signature:____________________________________ Print Name: _____________________________________
STATE OF FLORIDA COUNTY OF ______________________________________________
The foregoing instrument was acknowledged before me this ______________ day of _________________________, 20_____ by __________________________________________________________________. (Name of person acknowledging) (Print, type or stamp Commissioned Name of Notary Public)
_____________________________________________________________ (Signature of Notary Public)
Personally known ___________ OR Produced Identification____________ Type of Identification__________________________________ ------------------------------------------------------------------------------------------------------------------------------------------------------------------ PLEASE FAX THIS FORM ALONG WITH A COPY OF YOUR PROPOSED SITE PLAN TO EACH OF THE AGENCIES LISTED BELOW (SELECT ONLY ONE AGENCY PER FORM). PLEASE ENSURE YOU HAVE PROVIDED A RETURN FAX NUMBER. YOUR REQUEST WILL BE PROCESSED IN THE ORDER IT IS RECEIVED BY THE UTILITY AGENCY. PLEASE ALLOW SUFFICIENT PROCESSING TIME BEFORE YOU CONTACT THE UTILITY AGENCY WITH QUESTIONS.
Agency Fax Number/E-mail Questions Florida Power & Light 561-575-6333 [email protected] Utility Authority 561-624-2839AT&T Comcast Cable
[email protected] / [email protected]
TECO Peoples Gas System 561-741-4028 / [email protected]
561-616-1601561-627-2900 ext. 1462305-222-8248561-815-6659813-275-3783561-624-7830
We agree to the proposed construction under the circumstances described above.
________________________________________________________________________ ___________________________ (Utility Agency Signature) (Title)
_________________________________________________________________________ __________________________ (Print Name) (Date)
Select one agency only per form and indicate
selection by a check mark
REV 02/16/22
NPBCID 561-624-7839 / [email protected]
