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° �learwater Atlas#:2 Deparhnent
64q
� YC�i.....__ �iexation
ALL APPIICATIONS ARE TO BE FILLED OUT COMPIETELY AND CORRECTLY, AND SUBMITTED IN PERSON (NO FAX OR
DELIVERIES)TO THE PLANNING&DEVELOPMENT DEPARTMENT BY NOON ON THE SCHEDULED DEADLINE DATE.
A TOTAL OF 13 COMPLETE SETS OF APPLICATION AND SUPPLEMENTAL MATERIALS (1 ORIGINAL AND 12 COPIES) AS
REQUIRED WITHIN ARE TO BE SUBMITTED FOR REVIEW BY THE DEVELOPMENT REVIEW COMMITTEE. APPLICATIONS
AND SUPPLEMENTAL MATERIALS ARE REQUIRED TO BE COLLATED AND STAPLED INTO SETS.
IT IS INCUMBENT UPON THE APPLICANT TO SUBMIT COMPLETE AND CORRECT INFORMATION. ANY MISLEADING,
DECEPTIVE,INCOMPLETE OR INCORRECT INFORMATION MAY INVALIDATE YOUR APPLICATION.
THE APPLICANT, BY FILING THIS APPLICATION, AGREES TO COMPLY WITH ALL APPLICABLE REQUIREMENTS OF THE
COMMUNITY DEVELOPMENT CODE.
APPLICATION FEE: $0
IMPACT FEE/ASSESSMENT FEE: TBD Information on Impact Fees orAssessment Fees is available from
the City of Clearwater Engineering Department(562-4747).
PROPERTY OWNER(PER DEED): t ` �� ����1(1
MAILING ADDRESS: '�, r ° � '(� � "3'3�j
PHONE NUMBER: �1'�1 —ai�-U - �'133�
EMAIL: l 1��- ply n� � o���r�.�.l .GUrv1
AGENT OR REPRESENTATIVE:
MAILING ADDRESS:
PHONE NUMBER:
EMAIL:
ADDRESS OF SUBJECT
PROPERTY: `��� C,,V 0.�('1S �`r . L��G�,L.v..)C'x.�2-�Ir' �.— 33�I��
PARCEL NUMBER(S): �� - 29 -- 1(� — J�}'3q2— �(p—O�tQQ
LE6AL DESCRIPTION: �fl�� ��te� ���(rQ,�,� 1� Q�,d R LIC(.d t,0�'S .Z1� `��q
?
CURRENTCITYSERVICES: SANITARY SEWER SOLID WASTE � WATER
REQUESTEDCITYSERVICES: � SANITARY SEWER v*' SOLID WASTE
(select all that applyJ
Planning 8 Development Department,100 S.Myrtle Avenue,Clearwater,FL 33756,Tet:727-562-4567;Fax:727-562-4865
Page 1 of 7 Revised 02/12
° Clearwater Planning&Development Department
Petition for Annexation
� Disclosure Statement
PROPERTY OWNER(PER DEED):���. � ��;�J'-{,� ��_�1('1(�
MAIUNG ADDRESS: `,1�j� �,���y�S ('�' �l \ o[,�Auar's..-{4_� �L 33�7
PHONE NUMBER: ��-1 ,Z.\� — "j'33
E MAI L: �^ ���'1�:l c� , � ��'t t � 4�� °C�'''�'1
AGENT OR REPRESENTATIVE:
MAILING ADDRESS:
PHONE NUMBER: rk jry1.L_
EMAIL: �`�
OTHER PERSONS HAVING ANY OWNERSHIP INTEREST IN THE SUBJECT PROPERTY:
NAME:
INTEREST IS:
SPECIFIC INTEREST HELD:
DOES A CONTRACT EXIST FOR SALE OF THE SUBJECT PROPERTY? YES �_ NO
CONTRACT IS:
PARTIES INVOLVED—NAME: PHONE NUMBER:
NAME: PHONE NUMBER:
ARE THERE ANY OPTIONS TO PURCHASE THE SUBJECT PROPERTY? YES � NO
PARTIES INVOLVED—NAME: PHONE NUMBER:
IV%��r. 1'1L1/lAl� �I1111AOCD.
11VIC. �Ilv�v� i�v�viV���.
ARE THERE ANY MORTGAGES OR LIENS ON THE SUBJECT PROPERTY? � YES NO
PARTIES INVOLVED—NAME:��,�,�5 �� i/` G;� �Q,1Q�/�(eP,HONE NUMBER:
NAME: PHONE NUMBER:
STATE OF FLORIDA,COUNTY OF PINELLAS
I (we),the undersigned, acknowledge that ail representations made in this application are true and accurate to the best of my
knowledge and authorize City representatives to visit and photograph the property described in this application.
Sworn to and subscribed before me this �'7� day of
� . I..l�Ckrv�.�.� , ZO �z- .by
% � '�,U�M �+�DUQ ,who is personaily known/has
L ��� ` oduced ��- �Arwt.v� Llcstn,S.2..as identification.
Sig at re of property owner or presentative
,,,,,���,,,,
Notary ' , ;':°� „��; NE E.JACOBS
� ,�f =. ; . ? Notary Public -State oi Fiorida
My com 'ssio xpires: ;,� �r: My Camm. Ex ir
Sig of p y owner or representative "'%:�F;�°.�`' Commission #EE 203806
Planning&Development Department,100 S.Myrtle Avenue,Clearwater,FL 33756,Tel:727-562�1567;Fax:727�62-4865
Page 5 of 7 Revised 02/12