COMMERCIAL WORKSHEET
10/96 PLEASE TYPE OR
PRINT CLEARLY
(08) REFERENCE PERMIT NUMBERS WELL TREE USE
WETLAND OTHER SEPTIC PERMIT #
ELECTRIC
Electric Company ....FL POWER & LIGHT in NORTH SOUTH TITVL MTLND
FL POWER CORP CLAY SALT SPGS PALATKA NSB
UTIL
Service Size ........ OLD Amps Volts Phase 1PH 3PH
NEW Amps Volts Phase 1PH 3PH
Number New/Altered Circuits Temp Pole Yes No
FLOOD ZONE (If Zone A, FEMA Flood Certification Form is required)
Is FLOOR LEVEL less than 12" above the Crown of ANY ADJACENT road? YES NO
Flood Zone B/C V A BASE FLOOD ELEV (A or V) Min Floor Elev .00
HVAC
Type of HEAT...Electric Gas Oil Kerosene Heat Pump A/C Solar
Costs of HVAC
.00
PROJECT COSTS & USE
Cost of Structure or Project (include labor & material) $ .00
PRIMARY USE OF STRUCTURE Number of Square Feet
(09) PLUMBING (Provide Proof of Water and/or Sewer Connections)
Number of PLUMBING Fixtures Water Pump Connections Public Water Connect.
Sewer/Septic Hookups TOTAL PLUMBING UNITS
County Utilities Available Yes No If COUNTY UTILITIES ARE USED, SERVICE IS
REQUESTED: Upon Issue Hold Until Called or Date / /
Number Gas Outlets SPRINKLERS ...# of Heads # Standpipes # Siamese
Number Gas Storage Tanks Underground Above Ground # Roof Manifold
(11) TREE PERMIT ***Tree Removal Permit requires 3 Site Plans showing trees to be removed and replacement trees.***
Clearing Date (DO NOT clear for 3 working days/excluding app. date)
Tree Information Compliance *** Permit DRC REVIEW
LOT SIZE Square Feet Frontage ft Depth ft
Reason for Tree Removal if Permit
COUNT DIAMETER TYPE REMOVED COUNT DIAMETER TYPE REPLACED
Total Trees Removed Total Area Removed Total Area Replaced
(12) USE PERMIT **Three Site Plans required showing width of drive at property line and edge of road.**
***Pursuant to Chapter 556, Florida Statutes, as amended, an excavator of the work performed under the scope of this application shall call
the "Sunshine State One-Call of Florida, Inc." at 1-800-432-4770, or New Smyrna Beach Utilities at (904)428-5721 not less than two nor
more than five business days before beginning excavation.***
Driveway to Paved Rd To Unpaved Rd Number of Culvert Pipes Size
Open Street Cut Paved Rd No of cuts
Unpaved Rd No of cuts
Bore and Jack No of Bore and Jacks
Roadway Const Cost of Roadway Const $ .00
Other (Specify)
(13) WELL & PUMP NOTE: ATTACH A SITE PLAN INDICATING THE LOCATION OF THE WELL IN RELATION TO SEPTIC
SYSTEMS, PROPERTY LINES, AND BLDGS. THE MINIMUM SETBACKS FROM SEPTIC SYSTEMS
ARE: DOMESTIC 75', IRRIGATION 50', PUBLIC 100', PROPERTY LINES 5'. FOR OTHER PUBLIC
SUPPLY APPLICATIONS, A COPY OF THE COUNTY HEALTH DEPT. PERMIT MUST BE SUBMITTED.
Well Information: New Installation Replacement Abandonment Repair
Domestic Irrigation Other Public Supply A/C Supply Injection Monitor
PVC Galvanized Black Iron Other
Jetted Combo Rotary Cable Tool S. Rotary H.S. Auger Other
WELL DEPTH (est) WELL DIAMETER
Pump Information: Pump Motor Horsepower Pump Intake Setting
Centrifugal Deep Jet Submersible Shallow Jet Turbine Other
(14) IRRIGATION INFORMATION: Total Number of Zones Will Chemicals be introduced?
Automatic Timing Device Yes No Water Well Comm/City Supply Lake Other
County Irrigation Meter Yes No
Atmospheric Vacuum Breaker Pressure Vacuum Breaker
Reduced Pressure Double Check Valve Assy
Electric Valve Index Valve Manual Valve Other
IMPACT FEE CALCULATION Provide 1 set of floor plans clearly stating the scope of the work.
(or a 4th set of plans)
SITE PLANS & PLANS:
Submit three site plans showing all structures and Septic System on property and three complete sets of construction plans to scale showing all proposed
construction to include foundations, fire walls with rating and tested assembly designations, exits and exit lighting, electrical, mechanical, plumbing, and heating
plans, all uses designated, fire resistive construction notes, door sizes and schedules and riser plans. No lined or graph paper will be accepted. Plans may be
required to be sealed by a Florida registered design professional. Sealed energy forms will also be required (1 long Original, 1 copy of front of Long form). This
may not be a complete list of everything necessary to submit for this permit.