CYPRESS GROVE COMMUNITY DEVELOPMENT DISTRICT
8756 Boynton Beach Boulevard, Suite 2100
Boynton Beach, FL  33472
          DATE APPLIED_________________
    Permit Application      PERMIT NO.___________________
TO CONDUCT ACTIVITIES IN DISTRICT RIGHT-OF-WAY OR AFFECTING DISTRICT FACILITIES

ACTIVITY PROPOSED: ___________________________________________________________
CATEGORY: □A  □B  □C  □D  □E  □F  □G  
(See attached Fee Schedule for Description of Categories) 
 □ Other__________________________________________________(Fee to be Determined by District)
*(Attach Sketch or Plan to Application if applicable)
PERMITTEE INFORMATION

PERMITTEE: _____________________________________	   PHONE:  ____________________________
ADDRESS:   _____________________________________
CITY:  	       _____________________________________	   STATE:  ___________   ZIP:  ____________
CONTACT PERSON:  ______________________________
_______________________________________________________________________________
                                                            AGENT'S INFORMATION         (INCLUDE A LETTER OF AUTHORIZATION)

AGENT:        _____________________________________   PHONE:  _____________________________
ADDRESS:   _____________________________________
CITY:  	       _____________________________________	   STATE:  ___________   ZIP:  ____________
CONTACT PERSON:  ______________________________
_______________________________________________________________________________
SITE INFORMATION / PROPERTY CONTROL NO.
00– 			–			–			–00–000–					
														
               Range                   Township                   Section                                                   Tract Number     

PROJECT SIZE & SITE LOCATION:  ________________________________________________________
(DESCRIPTION)   __________________________________________________________________________

The PERMITTEE hereby attaches a check in the amount required by the District's current fee schedule payable to the District and further agrees to pay all administrative, engineering and legal costs incurred by the District in reviewing this application.  The PERMITTEE hereby certifies that he/she is the fee simple owner of the property adjacent to the District's Right-of-Way and gives authorization to the District to file a lien on said property for the above referenced costs, should they not be paid.  The APPLICANT understands these costs are to be paid whether the permit is approved or denied.  In the event this application is approved, the permittee will be required to execute the District's then applicable Permit, along with the Standard General Conditions, and any special conditions deemed warranted by the District.

SIGNATURE OF APPLICANT: ____________________________________________  DATE: __________________________________________

                                                                    APPROVAL                               (DO NOT WRITE BELOW THIS LINE)

DATE:  _____________________				___________________________________