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Planning,& Qeveloprt�ent'U�partment
Pe�iti�n for An�ex��ian
ALL APPi1CATlQ�+iS ARE Tt3 BE FI � 224 pq�M ST
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A Tt�TAt pF 14 CQMPI,£TE SE�'S Chamusco, Karen
REQUIRED WiTHIN ARE Tt3 BE S Zoning: Low Medium Densiry Re Atlas #: 251g
ANC? Sl1PPLENI�NTAL �VtATER1AL5 ARE REQIlIKtu � v oi. i,..�...._ __
'i'ED iN PERS(�N (NO FAX t?R
LEb flEADLINE DATE.
��i�iraA�. A�va �.� cc�P��s) As
1 COMM!'�iEE. APPl:ICATIOi'�fS
S.
IT �S iMCl7lU";SEid?' UPO�i TH'E 4PPLlG�N?' TO SL.�BNIIT C011IIPL�TE ANL3 CpRRECT 1N��RNtATIC?N. ANY N1iSLLA�3ING,
pEC�PTIV�, INCt}MPI.ET� OI2 INCORR£C!` IRiFC?RM,�4Tit7N IVIAY I�VALIDA7E YOL1R APPLICATttJN.
THE APPLIC14Ni, BY �I�I�VG THIS APPLiGA7'10lJ, AGit�E5 ''�'O CON1F'LY 'I�il17H ALL APPLlCASLE REQ�lIREilAEN7S OF THE
CO�VIMUNIT'Y DEIVELOPMENTCODE.
APPLICATIO� �EE:
t�r�acr ���/ass�sS�nEr�' ���:
$�
TBD lnformatian on lrnpaci Fees orAssessmen# Fees is available trorn
#he City of Ciearwater Fngine�ering Department (562-4747).
�'R�'3PERTY f3WNER (P�R i?EED}. Karen Chamusco
MAiUNG ADDRESS: 1224 Paim Street, Clearwater, �L 33755-1129
PHONE NUMBER: ,���'�' - ,:�� f "' ��� ,`� j�
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E�11AIL- _._._..__„
AGENTOR REPRESENTAiiVE:
IVIAiLIN(i Al�7Ui��SS:
P}iONE NUMSEfi:
EMAIL:
AUDRESS Of SU�JEGT 3224 Palrn Streei, Clearwater, FL 33T55-3129
PROPERTY.
PARCEL NUMBER(S}: Q3-29-15-15840-0p1-0320
LEGAL DESCRIPTlONf: Cloardun Bloek A, �ot 3z
[IJRREiVT CiTYSER`VIC�`S: SANITARY SEWER
RELjt1�37ED C1"iYSfR11►CES: ' SANITARY SEWER
(ssiect all that apply)
SDLlC} WASTE
�'- {
SOLIi> W,ASTE
'��f WATER
'& »>'�'€,^� �, t�e��.�af.,��?ari �'��a�r�.m�nt, 'Et�O �. i�lyri�� da.?ran3:�, i.4z�±°4.r�rat�-r, r'�. 33I;�� "a%. 7�7-6�2-��57; 'r`,a�; ;'?T-562-�8��
3 r�9 "9
�^dCt� :. �--. r i�'+��1:5LG� �i�1�:f �
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o , � ; : Planning & D�velopment Department
'� �� '�� ������ " "
Pet���on for Anne.�at�on
U Data S��et
�'LEASE ENSURE 3HAT TH� FOLI(7�fIIfiI1�G ItVFORNIATIQ�N IS FiiiED OUi, IM lTS EN7iRET'!. FAILUitE Ta �COfV�PLETE TH15
�pRMI WtiL RESULT )ht YDUR APPLiCATiQN BEIlVG FOUND INCOMPLETE AND PQSSIBLY DE�ERRE� UNi1L THE FQLLOWING
�'1��'LlCATIO[V GY.r.LE.
�U7UR� LAND t15€ PLAN DESiGNA7101d
PRESfitiiT {Ct�UNIY): Residential Urban (RU)
R�QIiESI"ED tClTl}: Residentiaf Urban (RU)
�it)NIMG DISTRICi
PRESENT (CQUNTI'): R-4, One, Two, and Three Family Resideniiai
REQUESTED (CI�'!): Low Medium Density Residentia! {LMDR}
SITE AR�A: 0.141
512� OF L3EV�LQPMENfi ;
Existing; 1 Unit
Proposed: 1 Unit
(e.g., number af units, hofet roams or
I�OrT- �aSidP»itclt St�UOr� fOOtt�ag!
acres
USE O€ PRpPERTY:
Existing (currently onsi#e):
Proposed (new us�, if any;
plus existing i# to remain):
!f residential use, is unitfs3
ren[al?
S'iATE OF FL�JRlDp, tUllN7Y Of PlNELLt1S
:{vre}, the un�ersignae+, ackr,ow3edge ihat a!! representations m�de in ihis appiica27i?R 8!L' iCU° and accurate t� the besi of my
knawledge and authflrize [ity representatiues to visii and photograph the property descr�bed in this application.
Sworn to and subscribed before rne this �-� day af
�J'� �- 2t�! . by
�. � �
/��,�,y'',�Z � . ,��;1.-��%� G C � �"�t�' �' �A�rl �- ���jL)�f} , who is personaliy knownJhas
property owne`f or representative
Signature of �rop�rty pwner or representative
. �
proriu�ea 'C�..� 1� as iaenii��ca€ian.
�...---� C �'% s�""i ,�hj '711�a�
pYt'Si't1i5S101'f 2X�71r£5: �°�
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'�ri ..
Not�,{Y puCili�C SL&tB of F1Dfrda
� �_����..��.f��'r��
ExD�6310It5f2p17 _ . ,
Plannirsr�} $� PC}�velcrpstz�n4 S���attrra�n*, ?(?(3 S. �Ulyrt3e �,s2nu�, Cl�arwrafer„ ��. 33756, ie6� 72?-�62�i5&7; �=a�� ?2?»562-A�fiS
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Planning & Developrr��nt Departmeni
Fetit7ion for Annex�tian
Subm�ttai Package Instructions & Checl+tlist
IN At?D#TI4IV TCi iNE C{)MPLETED Al11I�EXAiION PE7'lT1pN FflRM, ALL PETiTION Ff?�t AhEIVEXATlG1N PACKA�ES SHALL
lI�CL!!D£ A 5UBMITfAL PACKAGE THAT JNGLUDES THE FOLLU1n/ING:
0 Signed and sworn (nvtarize�d) disclosure of interest statement (form attached).
D If the property is not a plaited 1ot of record, a current suruey identifying tfie d9mensians, area and location of the
property having been prepared, s+gned and sealed by a land surveyor currently regisierer� in the State of Florida within
the most recen# 1� mr�nths. (NOte: Submii two capies only]
� 1f development is to be initiated priar to subrr�ission of an annexation petiaion and/or prior to ihe effective date of the
annexation, requisite site plans, plat, and engineering plans,
❑ Terms o# a psQposed Agreement to Annex, if any.
❑ tf the proposed annexation requires a change in the land use classification and zoning category assigned to the
property, a jt.istification ft�r sunc �hange musi be submifited i� writing. If the requesied �aning is not consistent with the
Future L�nd Use Map af the City of Ciearwater Comprehensive PJan, ihe applitant wiH be required to file a companion
applicatlon to amend the map.
0 Proo# af ownership {e.g., copy o# dee�l, title insurance policy, or oiher instrument demanstrating ownership). [Note:
Submit twn copies on/yj
D If conr�ectipn to city services is �iesired prior ta the effective date of #he annexation, applicant must provide natari2ed
Retition for Annexation Supplemental Sta#ement {form attac#�edj, (Note: Submit original only]
C7 ff applicant is designating an agent/representative to work with City, applicant must provide notarized Affidavit to
Authorize Agent/Representative (#orm attached}. [Note: Submit originol onty�
INFORM,ATIrDN REQUiRED TU COMPLETE 7HE PEiITiaN FQR ANNEXATIi)N APPLlCAi1flN ANO DATA SHEE`!' �AN BE
FVUND O�i THE FQLLOWING DOCUMENTS ANDJOR ONUNE AT TNf FOLLOWING 'WEBSITES. 1F THE APPUCAN7 IS
UNCERTAIN WHERE TO LUCATE THIS IN�ORMATION UR IVEEDS AD�ItIONAL ASSISTANCE, Pi.EASE GUNTAGT THE
�'I,ANNING ANfl C?EVE�.OPMENT DEPARTMENT, LCaNG RAiVGE Pl.,AfVN1NG p1Vi5It3N A? 72�-552-4567.
CI PARCEL NUMBER (Parcel i.b_ Number) can be #ound on the Warranty beed. 1t can aiso be found by searching the
Pinellas County PropertyAppraisers Of€ice website at www.pct�ao.o�� (sear�h database by address).
❑ LEGAL D�SGRIP71+C1N can be fe�nri nn the Warrant� Deed, lt can also be found by viewing the property record online at
the Pinellas County Property Appraiser's Office website at www.pcpaca.or�.
� FUTURE LAND USE PLAN C�ESIGNATIQN (C�U�Vi`l} can be found by viewing a Property Repart using Pinellas Cauniy's
F'ublic G15 V'sewer availabie online at http:/1�is.pinellascounty.ortJqublic �is1. Search by property address or Parcel I.D.
Number and repc�rt wii( appear.
❑ FUTURE LAND USE PLAN DESIGNAiIOPJ (Ct7Y) is typically the same as #he land use designation in Pinellas County, unless
applicani is proposing a change (see submitta! �ackage requirements for more informationj.
C1 ZQNING DISTRICT (COiJNTY} can be found by viewing a Prnperty F�eport using Pinellas County's Public GIS Viewer
availabl� online at htip: / �s,pinellascounty.orgjpu�lic �s/.
� ZONING D15TRIC1" (ClTYj can be foun� by contacting the �'lanning and D�aelqpmeni De�artmen# or viewing the City's
Zoning �ltlas, avaiiable anline at
ht2p;//www. mvclearwat�r_com/�ov�d�ptslpwa Jen�in�pubiicatsanslen�atlaslatlas.asp.
(� SITE AREA (ACRES) can be �ound by viewing a�roperty Report us�ng Pinellas County's Pub�ic Gi5 Viewer available c�niin�
�t http:�/�is.pinellascounty.or�j'public �is%.
�3an�3n� �� {�eva€�n��; 4 ���artr,��n:, '!�G :�. �liyz;.l� Tt+r�r�aa�, �i�a�n,e�tor, �� 33Y�b, "s�l: 't;t�-5��-�557; �-ax: 72�-5Oi--=18�5
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ATTElVDA1dC� A� PU�lIC HEAR�NGS
Pl�nning & i?evelc�p�n�nt Qepartamer�t
Petition fo�r Annexation
Inforrnation fc�r A�plican�s
The applic�nt or applicant's repre>entative i� eneouraged to attend City Counci! public hearings unle�� the ann�xa#ian
pert�ir�s to a property deveioped or to be developed with one single fami}y dwelling.
57ANDI4RUS FQfi AN1'J�XAT1flN
In cietermining whether t� annex a pro�erty, the City sha{i consider the extent tc� which:
G7 The proposeti annexation wiil impact publ�c services (e.g., water, sewer, police, parks, etc.).
❑ The proposed annexat�on is consistent with the City of Clearwater Comprehensive Plan.
D The prapased annexa#ivn requares a change in the future land use and zoraing classifications assigned to the
property as we}I as the juris�iiction t�r said change.
❑ Existing or propased development is consisient with City regufations.
� Terms of a proposed Annexation Agreement, if any, promotes the City of Cfearwater C�omprehensive Ptan.
f�RC3PEEt'iY OWMER A�GR�EMENT
Please be aduised thai, in consitferaiion of the annexa#ion, the property ovvners do hereby agree that:
❑ All structures and improvements which are erected upon said property subsequent to the date of this petition fo�
a��2xa�6�^ s�;a!! .'".`J3�i�t"`.�j% :vei� ��! L�P!'sca�!� Ci Y;,x C!�a�;.ater ;�g�la�ior,s a;�� or��na^��s as s�� f�rth :;� th� C;��
�ode c�f Urdir�ances;
C3 All resic�ential renta� units, inclasding single-family residences must comply with the requirements in ihe city's
residentia! rentai ordin�nc?, u!h��h reQuir�s th? �►-o�erty owner to obtain � Business Tax Rec+eipt ���e� �nnexa±�on
into the city;
0 if deveiopment is to be init�ated prior to submissian of an annexativn petition andJor prior 2o the effective date of
the annexatiQn, requisite site plans, plat, and engineering plans shall be submi#ted to ensure compliance with the
city's �nmmunity I3eveloQment Gode tsee 5ut,mitial rackage instruztions �heclt;istj. ft is re+comrnended tha� the
ap�l�rant meei ��+iih Pl�ns:�ng an� C�evel��me�t [�Q�a�ment staff to revie�+, plans and/or disc�sss the applicable fity
regulations;
� AU annexatians of residentyal t3u+�eilings o� e�ght dvsrelling units or mQre shali convey such recreation facilities fees
and r�creatian iand declicatian anc#Jor feQS in the amc�unt a�d manner prescribed by Chapter 54, Articie li of
Clearwater C�ode of Ordinances; and
O When any substandar€f abutiing sireet or utilities are subsequently upgraded by the City to meet City Standards,
said impravemeni(sj witl bQ done on an assessrnent basis, consi;tent vxith Gity p�ocedures #herefore.
P6arsni»e� � C?evei��rmcnL Dc��.sarPmers4, ;fl0 a. �yrf3� rRve�ue, Gi�ac�.vaYer, �L 3375�5, '�e�: 727-�62-4567; �'a�: 72�-�82--�SS
�a�e 4 c�4 7 ids�visesi i731�3
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> ���
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��+o����r caw��a {�E� a�e�}:
MAIt14V6 ADDRESS:
RHC}NE NUMBER:
EMAIL:
AGENT QR REPRESEi�TATlVE:
MAiUNG ADDRESS.
PF14NE NU�ufBER:
EtvtAl�:
Pl�nning & Development I3epar�mment
Petition far Annexation
Disclosure State�n►ent
Karen �hamusco
1224 Paim Street, Ciearwa#er, FL 33T55-112�
� �; ` � ��, l �' __ �r � �
._---.r, -
t}THER PERSt3N5 HAVING ANY �WNE�tSHiP INTERES"t' IN 7N� 5iJ8JECi PR4a�Eii7Y:
NAME:
INTEREST !S:
SPECIFIC INTER�S7 HELD:
ocses A conrr��a� �x�st �oa sa�.� o� r�� su���cr w�oa�arr?
CONTRACT IS:
PAR7IES INVOLVED—NAME:
iVAME:
AI2E TNERE AiVY C3P7�+DNS 70 PURCHASE TNE SUBJECT �Rt�PERTY?
PAR7IES INVQLVED—tVAME:
NAME:
ARE 7H�RE ANY MO�t'fGAGES UR UE�►S ON T1i� SUB.lECT PFi�C?PER7Y?
PAI�TIES INVOLUED-NAME:
NAME:
�
YES tr' NO
PHONE NUMBER:
PHONE NUMBER:
YES L,/� NO
PHONE NUMBER:
PMONE NUMBER:
YES
PHOfUE NUMBER:
PHONE NUMBER:
� NO
57A"fE OF FLQiiIDA, COUNTY Of PINELLAS
3(wej, the u�dersigned, acknowledge that aii representations made in this appli�ation are true and atcurate �o the best af my
knowtedge and authorize City represer�tati�es to visit and photograph the property described in this appiicatio
Sworn to and subscribed before me this �'�3 day of
� . ��. by
''� �� � ���3� , whn is personally knawnJhas
o�� ��
,,.,;�,`f�r � ,�'��.,*'�:'.���,,�'--���.:°- produced �- �.- as identification.
praperty owner ar representative
Notary , "
Uly mmission expires:
'' ' ` - fto��
Notary Pub�'C S�te of
JamesNl����s nas�os
Signature of property ownPr ar representative �� �.'�.� �"� "` i�����j�
. � �,.te�s � „��,
�.�v�...� ���,_.�._�..w __.�_.__�_._
� �'rdc��
r_ � w.er_ ., �_ �.,.,�..._��.,���. a _�._.� � _ � �.,.,:��'.�`�'_�.�_e..._..� ____.
F�ianrxi,:g � t����tc��s�-;c;r� �v�:,a�r�c��:, 1 ;t3 S. �ya'ta�� �,vv?�u�, �ar���aFcr, f� "s37:i6 "rvi: T��-�S2-�s67; ��x: 7�f-�62-�38��
��g�2 � �s ;? ;-s���is�� ��/'� 3
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Pl�nning & Development Department
Feti�ic�n fflr �nn��a: 'on
Affidavit to Authorize A�ent�Re�aresen �tiv�
1. Pr�ovide narnes of all property owners an deed —�'RINT full names:
Karen Cbamuscn
2. That (i am/we are} the owner(s} and record tiile holder(s) of the fotlowing described
3. Th�t th:s �rr�perty ��ns#=tu;es the �r�p°ny for :� h;�! � 3 request fQr (u°SCfIJE r°L�tlQ�):
4. That the undersigned �has%have) ap�oin2ed and �does/do) appoint.
as (his�'their} agent�sj to �x�cute any petitians or other documents cessary ta affect such petition;
5. ihat ihis a�ciavit has been ex�cute�i to induce the City of Clea at�r, Flarida to consider and act on the abnve
;;�scri�ei: �rope�`�y,
�. ihat site visifs tc� ihe praperty are necessary by City repres tatives in orde�- to process this application and ihe
owner authorites City representatives to visi# and photogr h ihe prc�perty described in this a�plication;
7. That (IJwej, the undersigr�ed authcsrity, her2by certiiy t�(at the foregoing is true and correct.
THIS
tUotary
Property Owner
��fl�erty Ovur.er
iE OF FLORIIIA, �OUNtTY O� D'lNE�.iA5
Property Owner
Prope:'ty Osv::�r
BE'rvit� ivi� �Hc +,��it3ER$i�i+i�vintJ GFFiGEr� �li�Y i.Giviivii�Sit'i�1c� BY THr i.r+V�%5 v� Ti-i'c STATc C3F FLOr�iDA, vi�l
DAY OF/
Pf RSQ�IAELY APPEAFEfl
1NH0 MAVING BEEN FIRST DULY SWORN
DEPOSED ANp SAY$!�'HA'i' HE/SHE FULI'! UNDERST�NDS TNE CpNTEt�lTS OF THE AF�IDAV�T THAT HEjSHE SIGijIED.
Nntary Public Signature
iVly Commissian Expires:
P6ann��g L� Develesper�erzi C2epart��r=Y, 1a�0 �. �yrYle Av�nz�e, Cle�nuater„ rL 337b6, T�I: 727'�S62d�SS7; F�x: 7'27-662-4���i
t �ge 6 �fi 7 Fi�uis2rB �3!'f3
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PRppER7Y p1IVN£R (pE� DEEDj: Karen �Chamusca
Plann�ng & Develapment �epartament
Petition for Annexation
Sut��plemental State�nnent
MAiLlNG Al?[3RE55: 1224 PaEm Streei, Cfearwater, FL 3375�-1129
C17"Y' t)F ClEARWl47ER CASE
NiJ�t1BER:
l(we,
(insert r�ames of afl property owners), havtng filed a Petition for Annexation regarding the abave property/case number,
grant consent, agree and �tknowledge #hat the Ciiy af Ciearwater may imrnediately or at a later time process the app)ication
to campletian, including adoption and recordation of related Ordinances, wiihout the necessity ta further notice me/us, This
Supplernenial Sta#emer�t shall superseda any �rovision in any A�reement to Annex executed by me/us or myjour
predecessors in interest.
l/we further agree and acicnawledge ihat liwe shall not rescind the Petiiion for Anr�exatipn or execute any documents
atfiemp#ing such rescission, and that any atternpted rescission shali be o# no force and effeci.
5iATE AF FLOR�DA, C�UNTI C?� PINEiLAS
I(we), the undersigned, acknowiedge that aii representations made in this application are true and accurate to the best of rr�y
knowtedge and auihorize City representatives to visi[ and photograph the p�operty described in this application_
5worn to and subscribed beforQ me this �`� ctav of
Signatif�r of property owner ('sndividual or autharized
repre ntative o# corporatian, partnership or other
e riyj
,�°...
5ignature af co-property owner
� �-- �, � � � b
- Y
�Atl� �- t.h{��Yi1�,iL"� , who is personally known/has
produced �A- as identi�cation.
�VOid (J +iC ' � �ry Pu3�iiG State ot ftorw
�� JamesWa9^�{
My tommission expires: '� ��,;�, F� a►s3ae
__.. � �' ��_ _� :.r.ry
r'�lar�n's?tg � ��ve;���n�rY ,:�a�asir�v;:�: 'i�J :�. ��31r�?e :�v�;-au€�, 4�i�aa~�aa2er, F E. �:;I��, '�ei: 7�1-.k,�2-�dS�7; ''r'aa.. 1.;. �-.�"i�a2—^��ur5e;
�age I J#,'Y �Z��!5:��� ti3("'s:s
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Planning & �evelc�pment Depart�ent
Pe�i�ion for An�aexat�an
ALL AFPLiGATiCi{�tS NRE 70 8E FILiED OUT COMPLETELY AND CORREGT'LY, AND SUBMITTfi? fiV PERS{31V (MO FAX OR
pELIVERIES) T0� TFiE PLANiVi�'JG & DEVELOPMENI' i�EPAR7ME�JT SY IV40A1 C�IV TFfiE SCNEDULED DEADIIN� [3A1'�.
A T07AL QF 14 CDh11PLE7E SETS OF APPiICATiON AtVD SUPPLEMENTAL MATERf�tiS (l ORIG11VA1. AIVD 13 COPtES) AS
REQU�REp W171i1N ARE TO BE SUBMITTE� FOR REVIEW BY THE DEVE�OPMENi REVIEW CC#MMiTFEE. APPi1CAT10N5
AN� SUPPLEMEh1T�11 MATEREALS ARE REQUlR£D TO BE �4lLATED AND S7APLED INTD SETS.
tT IS INCU1W18€�+17 LlPt3N THE APPLi�AN7' TO SUBMfT COMPLETE E1N1) CQRREGT lNFORMAT)t)W. }1NY MiSLEADli�i6,
DECEP7IUE, l�l£OMPLETE OR fldCt,�RRECT tNFORMATIO(V MAY iN1lALiDAiE YQUR APPIIZATtOiV.
SHE APPIiGANT, SY FiLI1VG THiS APPLiGAT10N, AGREES T� COMPLY WITN Ali APPi1CABLE REQUlREMENTS O� itiE
COMMUNITY DEVELOPMft47 CODE.
APPLICATION FE€:
lMPACT �EE/ASSESSNIENT FEE:
PROPfR7Y �WIVER (PER DEED):
MAILiNG AC3DRES5:
PHOiVE NUMBER:
EMAII:
$�
TBD lnformatian on fmpacf �ees orAssessrrrenf Fees is available from
the Crty of Clearwater Engineering Departmen# {�52-4747).
�
AGENT OR REPRES�iVTAT11f£; `
t� rt�r �",� �t-�' � ��� :'�_ � �'1`�''i S"� �-�� .
Jv'tAt:L1NG ADC3R�55:
PHONE NUMB�R:
EtUTAI�:
ADDitES� (�F SUB�IEtT
PRC)PERTY'; _ __ �-��. "'�1 �� �. M+ �a. �: � --- ---..�....��._
PARCEL 1VUA�IBER(Sj: D� Z'�� t$- t2DtoCa - o� �- a�� v
LEGAL t3ESGRlf'TIDN: ��i 4�i�?..�....�.%. e s � ��iA ��� �. �.�i.��` � t� —
Ct1RRFNT CITYSERi/lC�S;
R�QUF57EtJ C1TY5fR1l1Cf5: }�
(select �R thnr o�r�Iy} ---
SANI7ARY SEWER
SANITARY SEb11ER
SOLID WAS7E
'X SOLID WASTE
�C. WATER
�'iai�nin� � Dev�IG���c.ni� U..��.istr�wv�t, 10�] S. i�'l,irzf� ,e�r�um, i;3eaRri�t�:r, F3 3�i56, rel: 72i-51i3-d6i��i: Y=>�x: 727-��52-4$6�
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o Plan�ing &Develapm�nt T}epartme�t
h � ���-������ . . . . . . .
� : Pet�t��� f�r Anne�atian
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v �at� ��le��;
PLEASE �iVSi,1RE THAT THE �QLLQW3N6 ii�tFQRMA7IQN 15 FiLI.ED 0t1T, IN 17S ENi'lRETY. �Atll1RE TO COMPLETE THIS
Ft�RM WilL:l2ES1J17114 YE?t3R APPLiC�1T1tJN BEING fOUND'tNGC3MPLETE AND PUSSIBLY L�EFEF�FiED UNTIL THE FDtLC3WiNG
APPLtCAT1E�N LYGi�E.
�ll1"11RE LAiVD t3SE PiAN DESIGNATIQN
PRESENT (C(?UNTY7:
RE(2l1ESTED (Ci7Y).
ZONING DiSTRi�T
PRESENT (COUtVTYj:
RE(iUESTED {�I:TYj:
SITE AREA_ _.� . � �_ acres
SIZE OF QEVELOPMENT :
Exis[ing: � 4,1� � �
Proposed: _ '� i�v�+=+t'S
(e.g., number of units; hote{ rooms or
�..,.,- ; �si�e.^tici squ�re f�atage)
r.ir
USE OF PRLIPERTY:
Existing �currentiy an sitej: �A��
Proposed {new use, if any;
plus existing if to remain): ����
!f res��+eni�a! use, is anit(s;
rent�l?
���
STA7� OE FLOit1DA, CfllJi+17Y OF PINELLAS
I(we), the undersigned, acknowledge that:all representations mede in this apptication are true and accurate it� the best oi my
knowledge and authorize Gity representatives io visit and photograph the property descrihed in ih'ss appiicatian.
Sw�rn to and subseribed before me this �4- � day of
� , �+/`!/ . �y
��.. ,y4�, , who is personaliy knovvnf ha5
produ�eci �- .iiL ,.�",it ..,t�,}-��,'"��� a�id?ntiflc3iinci,
Signature of property owner o�'tepresentative
�iCJ�2f� �IU �1 r � ,J►Y %:tlt8�i �udI1C Juiw v. . ._
,� sa��w�a��
Nlyco issionexpi�es: ,��� MyCOrK+mis�ionF�o4s3o9
Signature af praperty owr�er or represeniative
Platinin� � Lieu�:topertei�t �e�aitmGa�t. 9Q0 S. ivtyrtie s�;uer�ue, Clearwvater, �L 33756, Tel: 727-562-�56?: F6ax; 727-552-�865
�a�r: 'L r�i 7 ftevis�ct Q3fi'�
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Planning & D�eveiopmer�t Department
Peti�i�ri fc�r ,Annexatian
u Submitt�� Package Instru�ctians & Checklist
t1V ApDiT10N TO TliE Ct3MPLETED ANNEXA7IOJV PE'TI'TIOnt FORM, AtL PEfITi4N �0�2 ANtVEXATlON PACKAG€S SHALL
lIVCLL�DE A SUBM1TiAl: PACKAGE TtiAT 1tVCLUDESI'i�3E FpLL4W{NC,:
II Signed and sworn tri4#arized) disclas�r� of intereststatement {form attachec3).
❑ If the property is no# a piatied 1ot o# record, a current survey identiiying the dimensions, area and tocatinn of the
property having been prepared; signed and se�i�d by a land surveyor curren�ly registered in the 5tate of Horida within
the mos# recent 12 months. (i�lote: Submit iwo copies oniyj
O if development is to be initiaied prior to submiss+on of an 2nnexation petition and%or priar to the effective date af the
annexation, requisite site ptans, plat, and en�in�ering plan5.
O 7erms of a proposed Agreement to Annex, i� any.
J if the prbpbsed annexatian requires a change in the land use classifi�ation and zoning category assigneci to the
property, � justificaiion for such change must be submitted in writing. If the requested zoning is not consistent with the
Future Land Use Map of the City of ClearwaCer Comprehensive Plan, the applicant Uril) 6e required to file a carr�panion
appiication to amQnd the map.
0 Proof of ownerst�ip {e:g., capy of deed, title insur�nce policy, or other instrument demanstrating ownership): (Note'
Submit two ca�ies onlyl
C� If connection to city serviees is desired Prior to the effective date af the annexation, applicant must pravide notarized
Petitian for Annexation Supplemental Statement (form attached}. [lVate: Submit originol onlyj
� If applicant is design�ting an agenL/representative to work with City, applicant must provide notarized A#idavit fo
Auihorize Agent/Repr�sentative (form attaGhed). [IVote_ Submit origino! only]
!�l�t�RM�Tln� u�r�i��aFt� Tt� Cptu►vt�T� THE PET{Tl�N FOR �11VNEXATION A?�L4CA7'!ON AN� 1�ATA S!��E'r ro,�v R�
�t3l1ND ON THE �OCLU4N'i�VG DUCl1NiE1VTS Ai+ID%OR tJi�LiNE AT 3HE FGtLLOWii�iG tNEB51�E5. 1� 7iiE A�'PEit�11i�1 i' i5
UIUCERTAiN W1�ERE TO i.00ATE TH15 IN�ORMA71f3N �R TNEEDS ADDITiI�NAI ASSISTANCE, PI:EASE CONTA[T THE
PIANIVINGAND E�EVEl.�PM�i�iT DEPARTMENT, LONG RANG£ PlAIVNING �IV1SIOt+1 AT 727=562-4567.
� PARCEL tVUN1BER (Parcel 1.D: Number) can be foun�i on the Warranty Deed. lt can also be found by searching the
Pineilas Cnunty Prope�'ty Appraiser's Ofifice website at www.pcpao.or� (search database by address).
t.,i L£GAL [�ESCRIPTICJN can be found on the Warranty Deed. It can aiso be found byviewing xhe property record pnline ax
the Pinellas Gounty Praperty Appraiser's Office website at www:pcpao.or�.
� FUTURE LAND USE PLAN DES16NA7)ON (COUI�iTY} can be found by uiewing a Property Report using Pinellas Count}r s
�ubiic GIS Viewer avaitable online ai http://Qi.s.pinellascoun2v.or�Jpublic �is/. Se�rch by property address or Parcel l.C3:
Number and report will appear.
� FUTURE tAND USE PLAN DESiGNATIC?N 4CITY) is typicaily the same as the land use designafiion in Pinellas Cou�ty, unless
applicant is prc�posing a change (see submiTtai package requirements fo� rr�ore information}.
C3 ZONiNG DIS7RICT (COUNTY} can be found by viewing d Properiy Report using PinelEas County's Public GIS Viewer
avaiiable online at htt��//�is �inellascountvor�/public �is/.
::� ZONI�lG DISTRiGT �C{TY) can be faund �y contacting the Planning and Develapment Uepartment or viewing the Gty's
Zoning Atlas, availabte online at
http�jjwtv��,myclearwater.com/�ov/cie�ts/pwa/enainf publica#ians/en�atlaslatfas.asp.
L.] SiTE A�EA (ACRES) can be faun� by viewin� a Property Repar� using Pine(}as County's Public GIS Viewer available anline
at htt �l��k�.c�inel6ascc�untv.or�lt�ub3ic oi�%.
AVanni��� �. qe��e�apmen2 C5�pe3rlmeni. 10Q S. �lyrrle u.vanue, Clr�arcva3�:r. FL 33�755. T_�1: 7?.7-5S2-�So7: rax: %27-5�2-4365
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;�'.e'•ti5c;ct 03. 13
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AT�ENDANGE Al' FL18L1GNEARIlV�S
Pl�inning & D�velopn�ent De}�aartment
Petit�on for Ar�nexa�tion
�nfo�rn�tion for A�piicant�
The applicar�t or applicant's repr�sentat�ve is encou�aged ta attend �ity Gouncil public he�rings unless tiie annexation
pertains to a property developed or to be de�reloped with one single family dweiling-
S7ANDARi?5 FC?R ANIVEXATION
!n determining whether to annex a property, �ne �i�y snaii c���siuer the exter�t t� w,`�ici�:
� The praposed annex�tion wiil impa[t pub9ic services (e.g., water, sewer, Police, pairks, etc.j-
0 The pro�aased annexation is tonsistent rvith the City af �learwater Comprehensive Plc�n.
� The proposed annexaiion requires a change in the €uture land use and zoning dassificatians assign�ct to the
property as well as the ju�isdittion fc�r said change.
� Exis#ing or praposeci development is consistent with City re�ulati�ns,
I� Terms of a proposed Annexatian Agreement, if any, prflmotes the Gty of Glearwater Compreh�nsive Pian.
FRdPERTY OWtVER AGREEM�NT
Please be adviset! that, in cnnsideration of Lhe annexation, the property owners do hereby agree that:
� All structures and irnprovemersts which are erected upan said property subsequent to the date o# this petition for
�,nr2xatior sh2i� corr.�iy vvith �!j znp!ic�ble City Qf Clearwater regulations and ordinances as s�t forth in the �ity
Code of Ordinances;
t:l All ressdenti�i ren#al units, including single-family residences must comply wiih the i-equirem�nts in the city's
residential renta) ordinance, which requires the property owner to obtair► a Business Tax Rece':pt upon annexation
inta the city;
C� �f development is to be initiated prior to submission of an annexation petition and/ar prior to the ef#ective date of
the annexation, requisi#e siie plans, plat, and engineering plans shalt be submi##ed to ensure'corr►p{iance with the
tity'S'Corrtmunity De?relopment Code {see 5ubmittal Package Instractions CF�ecktistj. It is recommended that the
ap�Iicant meet with: Planning and pevelopment Department staff to review plans and/or discuss the applicable city
regulations;
� kl1 ani�sexatians of residential dwe!lings of eigh: �v:e!fing ur�its �r mcr� shal! convey s�:ch r�creati�r� #acilities fees
and recreation tand dedi�atior ar,d/or fees irz the amount and manner prescribed by Chapt�c 54; Ar�icie i; �f
Gkearwater Gode of Ordinances; and
� When any substandard abutting street ar utili*.ies are subsequpntly �pgraded by the City to meet Gity Standards,
said improvement(s} will be done o� an assessment 6asis, tonsistent with �ity procedures therefore.
��anuiiig & q�vedAprrrerif Dep2krL�t�etat. ifla 5. �JiyrilE Aver�uc. Gfearuater, Fk 33756, i�L' 727-�62-45�7; �=ax�� t?7-562-�t36:,
Pac�e � =>9 7 fte�iseci 03f13
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F'ROPERTY OiNNER (PER DEEB}:
MASL1tVG ADDFtESS:
PHONE NtJMBER:
EMAIL:
AGfNTOR REPRES£N7'ATItIE:
MAILiNG ADRRESS:
PNONE Nt1M8ER:
EMAIL:
Planning & I�evelopm�nt Departnr�e�t
Petitic�n �ar Annexation
Dis�lQSUre Statement
�TH£R PERSOtdS HAViN6 AIVY OWNERSFIlP lNTEREST IN THE 5UBJECT PROPERTI:
NAME:
INTEREST IS:
SPECIFIC It�7ERE57 HELD:
DC7ES A CC7i+ITRACT fXiST F��i SA.LE Uf 7HE 5�J81Et'i PftOPERTY?
CONTRACT IS:
PARTIES INVOLVED — NAME:
NAME:
ARE TNERE A1VY f��T1�i�1STt3 PURGHASE TNE SUBI�CTPRORERTY?
�ARTIES INVflLVED— NAME;
ivi'�PviE:
ARE TNERE ANY MURTGAGES OR LIENS ON THE SUBIECT �ROPERTY?
PART{ES INVOLVfD —1VAMf:
NAME:
_ YES � NO
PHONE NUMBER:
PHONE NUMBEFt:
_ Y�s �_ r�o
PHQNE NUMBER:
YY1lJIVt IVUIVICStK=
YES
PHONE �1l1NIBER:
PHONE Nl1M�ER:
N�
STATE OF fL�RIDA, CQUIVTY OF PINELLAS
€(we), the undersigned, acicnowledge that a{9 represeniations made in this app{ication are true and accurat� to the best of m�
knowledge and authorize City representatives to visit and photograph the property described in this applicatio
Sworn to and subscribed 6efore me this �� day af
�- . ��'� . 6„
S�nature of property ovvner or representat
Si,;r.aturc �i;�roper*y otivr,er or re�resen#ative
,�°�i�t`�,i� ,�*�r`'��i ; who is personalfy known/has
produced „�L.1�.- �� as identification.
NotarY P , �`r�" ; -
. NowYY �ubtic State of �ta�cka
ivly c mmissio� ex�ires: �'� � James�'1a9+�
, ___ r� �305__
M„ .,.,..._
Ez�u�s tU11512UtT
i>lair�ir�g cg: De�ielOpme�i �r�attrracn2.'iDa 5. fi�ly�tle fi+ren��e, C}o�arra�ater. Fi_ 337�5, '�`el: 727-5S2-a567; �=ax: 727-56�-�$65
'r' f.)f' �;i t�P 7 � vi5�!'ti f.�.�,t'1 �;
� ���� �d������� .
Plan�ing & Deveir�pm+e�t Departrnent .
Petitian for 1���exati�n
� Aff�davit to Autl�orize A►.gent/Re�resent�tive
1. Proui�ie names oi all property awners an cleed — PRINT fuli names:
�'llli'���n ��ha�,'«,.�
T
2. That �i am/we are) the awner(sj and record title halder(s} of the following described prope�-ty:
����7 �� ��.� 1
3. That this property constitut�s the praperty for which a request far (describe request):
-.... C��n+� ��� �t� � —
4. 7hat the undersigned �has/have) appointed and (doesldo) appoint:
as (hisJtheirj ageni�s) to execute any petitions ar other dacuments necessary io affect sueh petitian;.
5. That this affidavit has been execated io induce the City of Clearwater, Fiorida to consider and act an the above
described property;
6. 7hat site visiis to the prnperty are necessary by City re�resentatives in order to process this appiication and the
owner autho�-izes City representatives to visit and photograph the property described in this application;
7. That {1%e), the und�signed �uthority, hereby certify that the foregoing is true and carrect.
��}�_��%�-%'��°���_ � � �.�..�- �—''�
Property £?wner ...� Praperty Owner
Property flwner
STATE Of FL(}RtL7A, COUN7Y 0� PINELtAS
Property ONtner
BEFORE IvIE THE t3NDERSIGMER, AN i3fF10ER DULY COMNfISStONED BY TNE LAWS OF THE STATE QF FLORIDA, �N
THiS �� DAY OF �_ � �''` � ; PERSONALiYA?PEAF2'ED
. ".�l'1 f�1� #�"Y'+r� ._— _ . _.�..� WHO NAViNG $EEN FIRST Dt1LY 5411�7RlV
DEPOSECi AND SAY$ �HRT N�%5Ht �i)LtY 171Viitt{J tP;l`tU� I f-it C.VIV i tiy I S C7f I tit AtF)�JP,'V11 I i-IA1 1-tt/Jiit }1t;i1VtU.
..�-'
�
�''" N Public Signature
/� �',,,�,n,�+l'tif'r�s�`�"'�
hiot'ary Se31JS�amp My Commission Expires: �,,r Naury�sw�cs�a�gof Flonda
� FF tf46305
_ �-- -......_._ __. _ ...._ _.... , , ,
�iy��� ExpK+�is10115IZ4'17
Plartrting 3. C��vslt��rnc�tt L)e�sa��ment, 100 S. AAyrtie Av�rtt�e, Cle�r.vater, rL 33755, 721: 727-b62-4567; �aX: 727-5&2-4865
-'=t;e o +si 7 r'ZtviSE:el'031'13
� Planning & Development Departmen#
} �i�.�:���t���� g�etition for Annexation
�
v Sup��emental Statement
PFiOPERTY OWIVER (PER DEEi7j:
MAfL4NC� ADDRESS:
C1TY C}F CLEARINATER CASE 1
tJUM6�}2: —.._._._._���1:1g�� �,�i'• ����t �'+� �Q_� i
�/we, -�`�r r "� .. �1�� j`��=� `-1
[insert names af all property owners], havi�gfiled a Petition for Annexation regarding the above property/case number,
prant consent, agree and acknowledge that the City of Clearwater may immediately or at a later time process the applicaiion
ta �ompietion, including adoptian and recorc9aiion of related flrdinances; without the necessity to further notice meJus. This
Suppiemental 5zatement sh�11 supersede any provision in any Agreernent to Annex executed by me/us or my/our
predecessars in inierest.
iJwe further agree and acknowledge that 1Jwe shali not rescind the Petition for Annexation or execute �ny documents
�ttempting s�ich rescissior�, and that any attempted rescission sha11 be of na force ar�d effect.
STA7E bF FLC3Ri�A, CC3ltNTY OF PINELEAS
I(r,ve), the undersigned, acknowiedge that all representations made in this appiication are true and accurate to tfie best of my
kno�vledge and auchorize City representatives to visit and pt�otograph the property uescribed in this application.
Swam to and substribed before me this �� day of
� �-� A - �Y
� ��?„'�y1 ��r ___ , who is personally knowr�/has
y�f roduced � �.�- {r�-• , as identification.
.a'�Y�,.,..� i� , ,/!-'.' i:.7.�,r ,ra �-irs P
Signature of proper:y awner {individua{ or auth�ori;
representative of torporation, partnership or othe
entity)
My commissipn expires:
Signature of ca-property ovvner
9 Notary PubiiGStaie vf Ftonda
,—�a�sres Wag�Qr
� Wly Commission F� 046308
c.nioes 10J15Y2017
rEZ.nni��ci `. Or�„���loprrie��k Dep�rtni�:31t, 5�00 S, t7�yrfl� rtv;,7rt�ae, Clc3arwsaE'Y, ; t_:;3756. �7U�1: 7�7-5�7_-5567: Fa;7: 727-5o2-d36�
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T�. 2013356405 BK: i8214 PG: 14�2, �1/09j2013 at 02:59 PM, FZECORATNG 2 PAG�S
1:� .�` ? D L3(?C STAMP CQLLECTiqN $� , 70 KEN BL7RK� , CL�F2K CJE' COURT AND COMPTF20i,LEI�
P�L3ELLAS COUNTY, FL BY DEFL7TY Gi.+ERK; CLKPR03
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By � party, Csranwz, �� R�� R� M R M N�'�
W�ose post' office acidress is t 3� 2. R, ! G�--d 3� A}� i}�' C�1' �, � U i�t � U 11� _�' �... 3�"' ���
Ta se;cond, 7Part�y, Crantee, ��1 f�, t"`f'� ��"� f�1iA �j
Wtaose posk o�'ice address is � � ( 2.,, � � Ct� �e� � R 3'� � � t� �! � { 7U � �.: � �� �
'G�TN�SS�TH,'�at tke said f rst party, for good considera�ion aztd for the suna t�#'
� t� `=- ��.. v i s.... " 1�' .
I}o�iars (� �'�� ) Paid by ti�e se�nd gariy, the receipt
wh�z�evf is'hereby acknow�etiged, daes hereby rernise, release and �uitclaim urito the said
se�nd pa�ty farevcr, aii t�e right, title, ir��r�st and cl�im which t��xe sa�d first pax�y has in
and ta tke fo�lo�viug described parcei of 1and, and improvements �d appurtenaz�css
viu
tllez'�to �ti i�ie �OliiQty Of � i�L�A S..,�_r State of _��.,. ti R!�7 #i to w1t;
Legai deseri�ztia� of`I'roperty= ��., C3 ���'� 1J� �1
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day �nd ��ar first abc�ve �^itt�ra. Si�n�d, Ser�ecl ztnd d�V i� F�'
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PINLLZAS GC3UN3!Y F`Is OEF. REG. BK 18219 PG 1433
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Frint name of First Party, Grantor
Siguature of Second ��rty, C'rrantee
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Print name of Second Farty ,Grantee
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Addzess o� Preparer '
STATE O�
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COLFE�ITY OF �'�
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before me, � � '� �Z �}�l ,`c� �"-� � "" r-� _
1')�l�lw`�'.vva .. . r .. � _ ' _
personally known to me (ar proved to e ou the basis of satisfa�ctoary e. dence} to be the
p�on (s} whQSe z�ne{s) is/are subscribed to the withux ins�t.rumen# and a�knowledged tr�
me that �elshelthey ex�cuted xhe same im hislherftheir au2horiz�'I capacity(iesj. And that
by i�islher/the;� signature(s) on t�� instrument the person{s�, ar the entity upon behaif of
which the �n(s) actad, executed iiie in._rtnunent;
ri�#iant Kna�vn��'roduc� FD
Type af � � .��. �}-5'� " Cc�a - .�'! --2�1-�
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fl�F REG BK: 137�? PG; 93d7.1347
Uoc?ype;DE�O B�E�C9�2Dit�: 3�0,08
t7 Dt3G STAMP: �&37A0
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t-1_ ;-,t,�3, i�ueinat`ter iall�e�i th� ��-�rstt�r. t� �I���i�'CRAi�t r�l1NAY and SHANTI A��I1��1,Y, hus�a�nci and tivi%�, w}aos� �?ost ot�tice
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.;, i!=�.< <.:� �aifi iar�l ,it��3te in Pinelf��s Ct���ntv, Flot�ir�a, viz_�
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l�t��;et#1e�' »�ith all t}ae t�nem�nis, heredit�r�l�ents and ;�p}��,rten�ulc�s tt�e�-etn hc;ion�in� ar in any�vis� �:��;ertainin��.
"i'ci t-S��re �atttl it> ��t�Ic�, €he �,tr7�e in t�e :>ir��pEe ;'c�re��e�.
�1t�d [1ze w�rcintur l�erzbv cc�i•e��zRnts with s��id �rantee tl3ai tne grantc�r is Iati��fiilly sei7ec! ot` �zid iand in fiee sim��ie; [hat t:l3e ��r.s��i:�r
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