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2. Construction Within Public Right-of-Way
   All information must be filled-in completely
3. Return Completed Form to:
   City of Zephyrhills, 5335 8th Street, Zephyrhills, FL 33542 or Fax: 813-780-0005
5. Date of Application
   Date of Application
6. Office Use: Processed By
7. Office Use: Permit Number
9. Office Use: Copies to:

   1. Building Department

   1. Public Works
11. Project/Job Site
13. Project/Job Site Address
14. Project/Job Site Unit Number
15. Parcel Identification Number
17. Property Owner
19. Property Owner Name
21. Property Owner Address
22. Unit Number
24. City
25. State
26. Zip
28. Property Owner Phone
29. Property Owner Fax
31. Contractor
33. Company
35. Name
37. Contractor’s License Number
38. Email Address
40. Phone
41. Cell
42. Fax
44. Architect/Engineer
46. Firm Name
47. Sate License Number
49. Name
51. Address
53. City
54. State
55. Zip
57. Phone
58. Cell
59. Fax
61. Description of Project
63. Type of Driveway

    1. Commercial Driveway

    1. Public Access Driveway

    1. Residential Driveway
65. Length of Driveway
66. Width of Driveway
68. Right of Way Depth
69. Excavation in Linear Feet
71. Culverts Needed

    1. Box Culvert

    1. Corrugated Material

    1. Reinforced Concrete

    1. Other
73. If other culvert, please explain.
75. Construction Material

    1. Asphalt

    1. Concrete
76. Curb Cut Required

    1. Yes

    1. No
77. Headwall Required

    1. Yes

    1. No
79. Notice to Applicant
    If actual work exceeds scope of this description, additional permits or drawings will be required.
81. Utility Locations Required
    Call Before You Dig: 1-800-432-4770
82. Utilities Locate Confirmation Number
84. Attach Sketch of Driveway When Submitting
86. Affidavit
    Application is hereby made to obtain a permit to do work and installations as indicated. I certify that all foregoing information is accurate and that all work will comply with all applicable codes. I understand these codes shall take precedence over all approved construction documents, and issuance of this permit is verification that I will notify the property owner of Florida Lien Law requirement, F.S. 713.
88. Deed Restrictions
    The issuance of this permit does not ensure compliance with deed restrictions and I understand that additional deed restrictions may apply to this property.
90. State Codes & Standards
    All work shall comply with the current Florida Building Code, Public Works Design Manual and Florida Department of Transportation (FDOT) Design Standards (if applicable).
92. Note
    The City of Zephyrhills is not responsible for maintenance or repairs of driveways. Driveways shall not alter/interfere with existing storm-water treatment and/or conveyance.
94. Witness/Notary Public Required
    Application is void unless signed with proper identification and witnessed by a permit technician or notary public.
96. Property Owner Initials
    By signing this application: I certify that I have read and understand the owner/builder disclosure statement.
98. Applicant Signature
99. Date
    Date
103. Notary Or Office Use
105. Permit Technician Signature
106. (Or) Notary Signature
107. Date
     Date
109. Applicant Identification

     1. Personally Known to Me

     1. Produced Identification
110. Type of Identification
114. Office Use
116. Concrete

     Minimum 6 inches

     1. Yes

     1. No
117. Asphalt Base

     Minimum 6 inches

     1. Yes

     1. No
119. Asphalt

     Minimum 1.5 inches

     1. Yes

     1. No
120. Length

     Minimum 19 feet

     1. Yes

     1. No
122. Width

     10-foot minimum to 20-foot maximum

     1. Yes

     1. No
123. Existing Sidewalk

     1. Yes

     1. No
125. New Sidewalk

     1. Yes

     1. No
126. ADA Compliant

     1. Yes

     1. No
128. Expansion Material Required

     1. Yes

     1. No
129. Contiguous Parking Pad

     1. Yes

     1. No
131. Triangular Flare

     3 feet wide by 7 feet long

     1. Yes

     1. No
132. Visibility Triangle Okay

     1. Yes

     1. No
134. Side Set Back

     3-foot minimum right of way

     1. Yes

     1. No
135. Plan Review

     1. Yes

     1. No
137. Additional description of work as defined by Public Works Director and or designee.
139. Permit Application Approved by
140. Date
     Date
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141. Print Only

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