APPLICATION FOR INDIVIDUAL AND CONCEPTUAL APPROVALApplication for
Individual and Conceptual Approval
Environmental Resource Permit,
State 404 Program Permit,
and Authorization to Use State -Owned
Submerged Lands
Florida Department of Environmental Protection/
Water Management Districts
Effective December 22, 2020
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Form 62-330.060(1) - Application for Individual and Conceptual Approval Environmental Resource Permit, State 404 Program Permit, and
Authorization to Use State -Owned Submerged Lands
Incorporated by reference in subsection 62-330.060(1), F.A.C. (effective date: December 22, 2020) Section A,
Page 1 of 11
Instructions for Use of This Form:
This form is designed to assist you in submitting a complete application. All applications must include Section A -
General Information for All Activities. Sections B through H list typical information that is needed based on the
proposed activities and are only required as applicable. Part 1-C of Section A will guide you to the correct
sections needed based on your proposed activities. Applicants are advised to consult Chapter 62-330, F.A.C.,
and the Environmental Resource Permit Applicant's Handbook Volumes I and 11 for information regarding the ERP
permitting process and requirements while preparing their application. Internet addresses for Chapter 62-330,
F.A.C., and the Applicant's Handbook, Agency contact information, and additional instructions for this form can be
found in Attachment 1.
What Sections of the Application Must I Fill Out?
Type of Activity
Section
A
Section
B
Section
C
Section
0
Section
E
Section
F
Section
G
Section
H
Section
I
Fill in wetlands or
waters for a
single family
residence?
Y
Y
N
N
N
N
N
N
Y, if in
assumed
waters
Docks, shoreline
stabilization,
seawalls
associated with a
single family
residence?
Y
Y
N
N
N
Y, as
needed
N
N
Y, if in
assumed
waters
Wetland impacts
(other than
association with
an individual
residence)?
Y
N
Y
N
N
N
N
N
Y, if in
assumed
waters
Boating facilities,
a marina, jetty,
reef, or
dredging?
Y
N
Y
Y
N
Y, as
needed
N
N
Y, if in
assumed
waters
Any work on
state owned
submerged land?
Y
N
Y
N
N
Y
N
N
Y, if in
assumed
waters
Construction of a
stormwater
management
system?
N
Y, as
needed
N
Y
N
N
N
N
Constructing a
mitigation bank?
Y
N
Y
N
Y, as
needed
N
Y
N
Y, if in
assumed
waters
Creating a mine?
Y
N
Y, as
needed
N
N
N
N
Y
Y, if in
assumed
waters
If you have any questions or would like assistance completing this form, please contact the
staff of the nearest office of either the Florida Department of Environmental Protection (DEP) or
a Water Management District (WMD) (see Attachment 2).
Form 62-330.060(1) - Application for Individual and Conceptual Approval Environmental Resource Permit, State 404 Program Permit, and
Authorization to Use State -Owned Submerged Lands
Incorporated by reference in subsection 62-330.060(1), F.A.C. (effective date: December 22, 2020) Section A,
Page 2 of 11
Section A:
General Information for All Activities
Part 1: Name, Application Type, Location, and Description of Activity
A. Name of project, including phase if applicable: The Bluffs Apartments
B. This is for (check all that apply):
• Construction and operation of new works, activities, and/ or a stormwater management
system
❑ Conceptual Approval of proposed works, activities and/ or a stormwater management
system
❑ Modification or alteration of existing works, activities, and/or a stormwater management
system. Provide the existing DEP or WMD permit #, if known: Note: Minor
modifications do not require completion of this form, and may instead be requested by
letter in accordance with section 6.2 of Applicant's Handbook Volume I.
O Maintenance or repair of works, activities, and/ or a stormwater management system
previously permitted by the DEP or WMD. Provide existing permit #, if known:
9 Abandonment or removal of works, activities, and/ or a stormwater management system.
Provide existing DEP or WMD permit #, if known:
O Operation of an existing unpermitted work, activity, and/or stormwater management
system.
❑ Construction of additional phases of a permitted work, activity, or system.
Provide the existing DEP or WMD permit #, if known:
O A State 404 Program authorization:
0 Exemption 0 General Permit ❑ Individual Permit
f requesting an Exemption or General Permit provide Rule #, if known:
X
By checking this box, I hereby voluntarily waive, in accordance with Rule
62-330.090(8), F.A.C., the agency action deadlines in section 5.5.3 of Volume I in the event my
project also requires a State 404 Program authorization (other than an exemption) under Chapter
62-331, F.A.C., and request that the agency actions for the ERP and State 404 Program
authorizations be issued at the same time. (This is strongly recommended to ensure consistency,
and to reduce the potential need for project modifications to resolve inconsistencies that may
occur when the agency actions are issued at different times.) If this box is checked and the
Agency(ies) determines that no State 404 Program authorization is required, the Agency will
continue to abide by section 5.5.3 of Volume I.
Form 62-330.060(1) - Application for Individual and Conceptual Approval Environmental Resource Permit, State 404 Program
Permit, and Authorization to Use State -Owned Submerged Lands
Incorporated by reference in subsection 62-330.060(1), F.A.C. (effective date: December 22, 2020)
Section A, Page 3 of 11
C. List the type of activities proposed. Check all that apply, and provide the supplemental
information requested in each of the referenced application sections. Please also reference
Applicant's Handbook Volumes I and II for the type of information that may be needed.
❑ Activities associated with one single-family residence, duplex, triplex, or quadruplex that do
not qualify for an exemption or a General Permit: Provide the information requested in
Section B. Do not complete Section C.
❑ Activities within wetlands or surface waters, or within 25 feet of a wetland or surface water,
(not including the activities associated with an individual single-family residence). Examples
include dredging, filling, outfall structures, docks, piers, over -water structures, shoreline
stabilization, mitigation, reclamation, and restoration/enhancement. Provide the information
requested in Section C.
❑ Activities within navigable or flowing surface waters such as a multi -slip dock or marina, dry
storage facility, dredging, bridge, breakwaters, reefs, or other offshore structures: In addition
to Section C, also provide the information requested in Section D.
❑ Activities that are (or may be) located within, on, or over state-owned submerged lands (See
Chapter 18-21, F.A.C. https://www.flrules.org/gateway/ChapterHome.asp?Chapter=l8-21): In
addition to Section B or C, also provide the information requested in Section F.
❑ Construction or alteration of a stormwater management system serving residential,
commercial, transportation, industrial, agricultural, or other land uses, or a solid waste facility
(excluding mines that are regulated by DEP). Provide the information requested in
Section E.
❑ Creation or modification of a Mitigation Bank (refer to Chapter 62-342, F.A.C.
https://www.flrules.org/gateway/ChapterHome.asp?Chapter-62-342): Provide the
information requested in Section G.
❑ Mines (as defined in Section 2.0 of Applicant's Handbook Volume I) that are regulated by the
DEP: Provide the information requested in Section H.
❑ Other, describe: Please contact the Agency to determine which additional sections of
the application are needed. See Attachment 2 for Agency contacts.
D. Describe in general terms the proposed project, system, works, or other activities. For permit modifications,
please briefly describe the changes requested to the permit: The total project area consists of ±2.6 acres
(113,256 square feet). The project consists of a 28 -story apartment building (400 units), underground
garage structure, underground detention system and ground -level retail.
E. Project/Activity Street/Road Address or other location (if applicable): 112 South Osceola Avenue
City: Clearwater County(ies): Pinellas Zip: 33755
Note: For utility, road, or ditch/canal activities, provide a starting and ending point using street names and
nearest house numbers or provide length of project in miles along named streets or highways.
Form 62-330.060(1) - Application for Individual and Conceptual Approval Environmental Resource Permit, State 404 Program Permit, and
Authorization to Use State -Owned Submerged Lands
Incorporated by reference in subsection 62-330.060(1), F.A.C. (effective date: December 22, 2020) Section A,
Page 4 of 11
F. Project location map and Section, Township, and Range information (use additional sheets if needed):
Please attach a location map showing the location and boundaries of the proposed activity in
relation to major intersections or other landmarks. The map should also contain a north arrow and
a graphic scale; show Section(s), Township(s), and Range(s); and must be of sufficient detail to
allow a person unfamiliar with the site to find it.
Section(s): Township: Range: Land Grant name, if applicable:
Section(s): Township: Range:
1. Section(s): 16 Township: 29S Range: 15E
G. Latitude (DMS) 27° 57' 52.128" Longitude (DMS) 82° 48' 6.084" (Taken from central location of the
activity). Explain source for obtaining latitude and longitude (i.e. U.S.G.S. Quadrangle Map, GPS, online
resource): Google Maps
H. Tax Parcel Identification Number(s): 16-29-15-20358-001-0040
[Number may be obtained from property tax bill or from the county property appraiser's office; if on
multiple parcels, provide multiple Tax Parcel Identification Numbers]
I. Directions to Site (from major roads; include distances and landmarks as applicable): From US -19, take the
exit for FL -60 West toward Clearwater and follow it to Osceola Avenue. Turn left onto Osceola Avenue, and
the destination at 112 S Osceola Ave will be on your left near Clearwater Harbor..
J. Project area or phase area: 2.60 acres
K. Name of waterbody(ies) (if known) in which activities will occur or into which the system will discharge:
Clearwater Harbour
The following questions (M -O) are not applicable to activities related to an individual single-family
residence, including a dock, pier, and/or seawall associated with that residence.
L. Is it part of a larger plan of development or sale?
❑ yes ® no
M. Impervious or semi -impervious area excluding wetlands and other surface waters (if applicable):
2.44 acres or square feet
N. Volume of water the system is capable of impounding (if applicable):
Normal Pool: N/A acre-feet. Depth ft.
Maximum Pool: N/A acre-feet. Depth ft.
Form 62-330.060(1) - Application for Individual and Conceptual Approval Environmental Resource Permit, State 404 Program Permit, and
Authorization to Use State -Owned Submerged Lands
Incorporated by reference in subsection 62-330.060(1), F.A.C. (effective date: December 22, 2020) Section A,
Page 5 of 11
Part 2: Supplemental Information, and Permit History
A. Is this an application to modify an existing Environmental Resource Permit or to construct or implement part of
a multi -phase project, such as a project with a Conceptual Approval permit? ❑ Yes ® No (If you answered
"yes", please provide permit numbers below):
Agency
Date
Permit/Application No.
Project Name
B. Indicate if there have been any pre -application meeting(s) with the DEP, WMD, or delegated local
government, or other discussions, meetings, or coordination with other stakeholders or agencies about the
proposed project, system or activity. If so, please provide the date(s), location(s) of the meeting, and the
name(s) of Agency staff that attended the meeting(s):
Agency
Date
Location
Meeting Attendees
SWFWMD
10/24/2024
TEAMS
Chris Kuzlo, Zaid Dabash, Max Moody, Wade Stevens
C. Attach a depiction (plan and section views), which clearly shows the works or other activities proposed
to be constructed. Use multiple sheets, if necessary, a scale sufficient to show the location and type of works,
and include a north arrow and a key to any symbols used. Specific information to be included in the plans
is based on the activities proposed and is further described in Sections B-H. However, supplemental
information may be required based on the specific circumstances or location of the proposed works or other
activies.
D. Processing Fee: Please submit the application processing fee along with this application form and
supplemental information. Processing fees vary based on the size of the activity, the type of permit applied
for, and the reviewing Agency. Please reference Appendix D of Applicant's Handbook Volume I to determine
the appropriate fee.
Form 62-330.060(1) - Application for Individual and Conceptual Approval Environmental Resource Permit, State 404 Program Permit, and
Authorization to Use State -Owned Submerged Lands
Incorporated by reference in subsection 62-330.060(1), F.A.C. (effective date: December 22, 2020) Section A,
Page 6 of 11
Part 3: Applicant and Associated Parties Information
Instructions: Please complete the following sections. For corporations, list a person who is a registered agent or officer of the
corporation who has the legal authority to bind the corporation.
A. Applicant (Entity Must Have Sufficient Real Property Interest)
0 This is a Contact Person for Additional Information
Last Name: Picket First Name: David
Title: Authorized Signatory for Clearwater Bluffs LLC Company: Clearwater Bluffs LLC
Address: 111 Fifth Avenue, 9th Floor
City: New York
Home Telephone:
Cell Phone:
Middle Initial:
State: NY Zip: 10003
Work Telephone: 212-716-2583
E-mail Address: clearwaterbluffsllc@gothamorg.com
Correspondence will be sent via email, unless you check here to receive it via US Mail: 0
B. Land Owner(S) (If Different or in Addition to Applicant)
® Check here if land owner is also a co -applicant
Last Name: Poirrier
Title: City Manager
Address: P.O. Box 4748
City: Clearwater
Home Telephone:
Cell Phone:
First Name: Jennifer Middle Initial:
Company: The City of Clearwater, Florida
State: FL Zip: 33758
Work Telephone:
E-mail Address: jennifer.poirrier@myclearwater.com
Correspondence will be sent via email, unless you check here to receive it via US Mail: 0
C. Operation and Maintenance Entity(see Applicant's Handbook I, Section 12.3)
Last Name: Stevens
Title: Vice President, Development
Address: 111 Fifth Avenue, 9th Floor
City: New York
Home Telephone:
Cell Phone:
First Name: Wade Middle Initial:
Company: Clearwater Bluffs LLC
State: NY
Work Telephone: 212-716-2583
E-mail Address: wstevens@gothamorg.com
Zip: 10003
Correspondence will be sent via email, unless you check here to receive it via US Mail: 0
D. Co -Applicant (If Different or In Addition to Applicant and Owner)
Last Name: First Name:
Title: Company:
Address:
City: State: Zip:
Home Telephone: Work Telephone:
Cell Phone:
E-mail Address:
Correspondence will be sent via email, unless you check here to receive it via US Mail: 0
Middle Initial:
Form 62-330.060(1) - Application for Individual and Conceptual Approval Environmental Resource Permit, State 404 Program Permit, and
Authorization to Use State -Owned Submerged Lands
Incorporated by reference in subsection 62-330.060(1), F.A.C. (effective date: December 22, 2020)
Section A,
Page 7 of 11
E. Registered Professional Consultant
ZThis is a contact person for additional information
Last Name: Dabash First Name: Zaid Middle Initial:
Title: Senior Project Manager Company: Stantec Consulting Services, Inc
Address: 777 S Harbour Island Blvd Suite # 600
City: Tampa State: FL Zip: 33602
Home Telephone: Work Telephone: 813-223-9500
Cell Phone: 816-460-2620
E-mail Address: Zaid.Dabash@stantec.com
Correspondence will be sent via email, unless you check here to receive it via US Mail:
F. Environmental Consultant
DThis is a contact person for additional information
Last Name: First Name:
Title: Company:
Address:
City: State:
Home Telephone: Work Telephone:
Cell Phone:
E-mail Address:
ID
Middle Initial:
Zip:
Correspondence will be sent via email, unless you check here to receive it via US Mail: ❑
G. Agent Authorized to Secure Permit (If Different from Consultant)
Last Name: First Name:
Title: Company:
Address:
City: State:
Home Telephone: Work Telephone:
Cell Phone:
E-mail Address:
Middle Initial:
Zip:
Correspondence will be sent via email, unless you check here to receive it via US Mail: ❑
If necessary, please add additional pages for other contacts and property owners related to this project.
H. Real Property Interest
a. Permits are only issued to entities having sufficient real property interest as described in Section 4.2.3(d)
of Applicant's Handbook Volume I. Please attach evidence of the applicant's real property interest
over the land upon which the activities subject to the application will be conducted, including
mitigation areas (if applicable). Refer to Sections 4.2.3(d) -(e) for sufficient real property interest
documentation.
b. For activities that require a recorded notice in accordance with rule 62-330.090(7), F.A.C., please provide
either the complete legal description of the property or a copy of the pages of the document recorded in
the public records that contains the complete legal description. If the land upon which the proposed
activities are to occur is not owned by the applicant, the applicant must also provide copies of any right-
of-way, leases, easements, or other legal agreement which authorizes the applicant to perform the
activities on those lands.
Form 62-330.060(1) - Application for Individual and Conceptual Approval Environmental Resource Permit, State 404 Program Permit, and
Authorization to Use State -Owned Submerged Lands
Incorporated by reference in subsection 62-330.060(1), F.A.C. (effective date: December 22, 2020) Section A,
Page 8 of 11
Part 4: Signatures and Authorization to Access Property (Applicant)
Instructions: For multiple applicants please provide a separate Part 4 for each applicant. For corporations, the
application must be signed by a person authorized to bind the corporation. A person who has sufficient real
property interest (see Section 4.2.3(d) of Applicant's Handbook Volume I) is required in (B) to authorize access to
the property, except when the applicant has the power of eminent domain.
A. By signing this application form, I am applying for the permit and any proprietary authorizations identified above,
according to the supporting data and other incidental information filed with this application. I am familiar with the
information contained in this application and represent that such information is true, complete and accurate. I
understand this is an application and not a permit, and that work prior to approval is a violation. I understand that
this application and any permit issued or proprietary authorization issued pursuant thereto does not relieve me of
any obligation for obtaining any other required federal, state, water management district, or local permit prior to
commencement of construction. I agree to operate and maintain the permitted system unless the permitting agency
authorizes transfer of the permit to a different responsible operation and maintenance entity. I understand that
knowingly making any false statement or representation in this application is a violation of Section 373.430, F.S.
and 18 U.S.C. Section 1001.
David Picket � February 5, 2025
Typed/Printed Name of Applicant or S' • re •,/�• plicant or Applicant's Date
Applicant's Authorized Agent Au orized Agent
Authorized Signatory for Clearwater Bluffs LLC
(Corporate Title if applicable)
B. Certification of Sufficient Real Property Interest And Authorization For Staff To Access The Property:
certify that:
® I possess sufficient real property interest in or control, as defined in Section 4.2.3 (d) of Applicant's
Handbook Volume I, over the land upon which the activities described in this application are proposed and I
have legal authority to grant permission to access those lands. I hereby grant permission, evidenced by my
signature below, for staff of the Agency to access, inspect, and sample the lands and waters of the property as
necessary for the review of the proposed works and other activities specified in this application, upon advance
notice. I authorize these agents or personnel to enter the property as many times as may be necessary to make
such review, inspection, and/ or sampling. Further, if a permit is granted, upon advance notice, I agree to provide
entry to the project site for such agents or personnel with proper identification to determine compliance with
permit conditions and permitted plans and specifications.
OR
❑ I represent an entity having the power of eminent domain and condemnation authority, and I/we shall
make appropriate arrangements to enable staff of the Agency to legally access, inspect, and sample the property
as described above.
David Picket
Typed/Printed Name
Authorized Signatory for Clearwater Bluffs LLC
(Corporate Title if applicable)
February 5, 2025
Date
Form 62-330.060(1) - Application for Individual and Conceptual Approval Environmental Resource Permit, State 404 Program Permit, and
Authorization to Use State -Owned Submerged Lands
Incorporated by reference in subsection 62-330.060(1), F.A.C. (effective date: December 22, 2020) Section A,
Page 9of11
Part 4: Signatures and Authorization to Access Property (Landowner/Co-Applicant)
Instructions: For multiple applicants please provide a separate Part 4 for each applicant. For corporations, the
application must be signed by a person authorized to bind the corporation. A person who has sufficient real
property interest (see Section 4.2.3(d) of Applicant's Handbook Volume I) is required in (B) to authorize access to
the property, except when the applicant has the power of eminent domain.
A. By signing this application form, I am applying for the permit and any proprietary authorizations identified above,
according to the supporting data and other incidental information filed with this application. I am familiar with the
information contained in this application and represent that such information is true, complete and accurate.
understand this is an application and not a permit, and that work prior to approval is a violation. I understand that
this application and any permit issued or proprietary authorization issued pursuant thereto does not relieve me of
any obligation for obtaining any other required federal, state, water management district, or local permit prior to
commencement of construction. I agree to operate and maintain the permitted system unless the permitting agency
authorizes transfer of the permit to a different responsible operation and maintenance entity. I understand that
knowingly making any false statement or representation in this application is a violation of Section 373.430, F.S.
and 18 U.S.C. Section 1001.
Jennifer Poirrier
Typed/Printed Name of Applicant or
Applicant's Authorized Agent
City Manager
(Corporate Title if applicable)
. r : t t of Applicant or Applicant's Date
Author
d Agent
B. Certification of Sufficient Real Property Interest And Authorization For Staff To Access The Property:
1 certify that:
® I possess sufficient real property interest in or control, as defined in Section 4.2.3 (d) of Applicant's
Handbook Volume I, over the land upon which the activities described in this application are proposed and I
have legal authority to grant permission to access those lands. I hereby grant permission, evidenced by my
signature below, for staff of the Agency to access, inspect, and sample the lands and waters of the property as
necessary for the review of the proposed works and other activities specified in this application, upon advance
notice. I authorize these agents or personnel to enter the property as many times as may be necessary to make
such review, inspection, and/ or sampling. Further, if a permit is granted, upon advance notice, I agree to provide
entry to the project site for such agents or personnel with proper identification to determine compliance with
permit conditions and permitted plans and specifications.
OR
❑ I represent an entity having the power of eminent domain and condemnation authority, and I/we shall
make appropriate arrangements to enable staff of the Agency to legally access, inspect, and sample the property
as described above.
Jennifer Poirrier
Typed/Printed Name
City Manager
(Corporate Title if applicable)
StoLI\ Date
Form 62-330.060(1) - Application for Individual and Conceptual Approval Environmental Resource Permit, State 404 Program Permit, and
Authorization to Use State -Owned Submerged Lands
Incorporated by reference in subsection 62-330.060(1), F.A.C. (effective date: December 22, 2020) Section A,
Page 10 of 11
C. Designation of Authorized Agent (If Applicable):
I hereby designate and authorize Zaid Dabash, P.E. to act on my behalf, or on behalf of my corporation, as the
agent in the processing of this application for the permit and/or proprietary authorization indicated above and to
furnish, on request, supplemental information in support of the application. In addition, I authorize the above -listed
agent to bind me, or my corporation, to perform any requirements which may be necessary to procure the permit
or authorization indicated above. I understand that knowingly making any false statement or representation in this
application is a violation of Section 373.430, F.S.., and 18S.C. Section 1001.
David Picket
Typed/Printed Name of Applicant
Authorized Signatory for Clearwater Bluffs LLC
(Corporate Title if applicable)
P
icant
February 5, 2025
Date
Form 62-330.060(1) - Application for Individual and Conceptual Approval Environmental Resource Permit, State 404 Program Permit, and
Authorization to Use State -Owned Submerged Lands
Incorporated by reference in subsection 62-330.060(1), F.A.C. (effective date: December 22, 2020) Section A,
Page 11 of 11