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HomeMy WebLinkAboutCRA-R-25-0024 Exhibit CWater and/or Sewer Development Information Application Form for Water MIAM and/or Sewer Blanket/Agreement mtamtdade.gov Instructions: The Prop erty Owner, Authorized Representative, Contractor or Engineer must fill out this form, along with the checklist. All the information must be received prior to the acceptance of this form. Additional information may be required based on the project location and size of the water and sewer facilities to be Installed and will require a water and/or sewer agreement. APPLICATIONS WILL NOT BE ACCEPTED IF THE NECESSARY INFORMATION AND SIGNATURES ARE NOT PROVIDED. Project Name: Citizens Bank Proposed Project Address: 1367 North Miami Avenue, Miami. FL 33131 Property Owners Name: OMNI / Midtown CRA (Jason Walker- Exec. Director) Type of Entity: Municipal Corporation Property Owner's Mailing Address: 1401 North Miami Avenue aty, State, Zip: Miami. FL 33136 Property Owner's E-mail Address: jwalker@miamigov.com Daytime Phone Number(s): (1) 305-679-6869 (2) Reason for Connection Information tcheck all/any that applyl: 0 New Construction 0 Demolition g Remodeling 0 DERM Notice 0 Fire Protection Required 0 First Is this a "green" and/or LEED building? 0 Yes 0 0 Detached Addition 0 Attached Addition Time Connection 0 Other No Type of Units to be Constructed (please refer to Exhibit "a" Attached) # of Units andlor Square Feet: Type of Unit: (You may attach an additional fist If necessary) Construction Schedule: (# of units completed per calendar year) Proposed GPD: 4,241 SF. Restaurant Full Service 4,241 SF BY 2020 4,241 GPD 3,855 SF. Office Building (other) 3,855 SF BY 2020 193 GPD FOUO V: LOT: BLOCK: SUBDIVISION: 01-3136-009-0220 ALL OF LOT 16. AND THE NORTH 35' OF LOT 15 BLOCK 2 BALDWIN AND OXAR'S SUBDIVISION PLAT BOOK B. PAGE 47, D.C.R. Note: Any points of connection (POC) information that is provided is general and subject to prevailing rules, regulations, standards and regulatory requirements at the time of request for service. PRINT NAME: Thomas Donahue/Mark Castano (Keith & Assoc., Inc.) DAYTIME PHONE a: Of different from above) 954-788-3400 TRLE: Director of Engineering/Project Manager (Keith & Assoc., Inc.) EMAIL ADDRESS: (H different horn above) MCastano@keithteam.com/DSalazar@keithteam.com DATE: 4,9�1 For Weld use Only Plans Reviewer Approval and Date: Water Requirement: 0 Agreement ❑ Blanket Sewer Requirement: 0 Agreement 0 Blanket Water and/or Sewer Development Information Application Form for Water MIAM and/or Sewer Blanket/Agreement aNrr miamidade.gov applicable fee: Checklist: Please include a check payable to Miami -Dade Water and Sewer Department with the Water and/or Sewer Blanket/Agreement fees: Water Service Area Only (If the Project is in a water service area only) $100.00 Sewer Service Area Only (If the Project is In a sewer service area only) $100.00 Water and Sewer Service Area (lf the Project is in a water and sewer service area) $200.00 Additionally Water Supply Certification Leafier (If the project Is only a water service area) $90 00 0 Entity: Type Required Information Corporation State of Incorporation Public Agency Partnership Partnership Information Omni CRA/ Citizens Bank Limited Liability Corporation Managing Member © One (1) signed and sealed original boundary survey or tentative plat identified as "boundary survey" of the property, including location sketch (not older than two years). © One (1) copy of site plan and/or tentative plat showing layout of buildings and roads. El Proposed plan (or concept) of water and/or sewer connection and layout. I] Current property zoning designation (or submitted re -zoning application). Note: Zoning must allow proposed development See attached ZONING DESIGNATION EXHIBIT Miami 21 Zoning designation T6-24A-O "Urban Core" taken from City of Miami: miamigov.comlmiamizoning l Copy of Recorded Warranty Deed (if different owner from PTXA) I] Proof of any existing or previously connected structure, and the type or usage/occupancy of said structure. 0 DERM and/or DOH approval regarding sewage disposal (if available). No permits yet for proposed improvement/connection 0 One (1) copy of Fire Department requirements (if available). Fire department requirements not available at this time ACKNOWLEDGMENT:Please be advised that mixed use development (commercial/residential properties) connected to the same meter may not receive the minimum per unit life line discounted rate and will be billed at the Non -Residential rate. Under penalties of perjury, I declare that I have read the foregoing and that the facts stated in it are true, to the best of my knowledge and belief. TITLE DATE yYfii t1 /- J / Miami -Dade Water and Sewer Department -New Business Section P.O. Box 330316 -Miami, Florida 33233-0316 786.268.5209 3575 5. LeJeune Road, Room 114