Fillable PRIVATE DOCK PERMIT APPLICATION PINELLAS COUNTY WATER AND (Pinellas County Clerk of the Circuit Court and Comptroller)

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PRIVATE DOCK PERMIT APPLICATION PINELLAS COUNTY WATER AND (Pinellas County Clerk of the Circuit Court and Comptroller)

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BROWSE PINELLAS COUNTY CLERK OF THE CIRCUIT COURT AND COMPTROLLER FORMS

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Direct all correspondence to:
Clerk, Water and Navigation, 5
th
Floor Application # ___________________________
315 Court Street (OFFICIAL USE ONLY)
Clearwater, FL 33756
PRIVATE DOCK PERMIT APPLICATION
PINELLAS COUNTY WATER AND NAVIGATION
I. PROPERTY OWNER INFORMATION:
A. Applicant’s Name: __________________________________________________________________________
B. Mailing Address: ___________________________________________________________________________
City: ____________________________________________ State: __________ Zip: ___________________
C. Telephone No: __________________________ E-mail Address: _____________________________________
II. AGENT INFORMATION:
A. Name: ____________________________________________________________________________________
B. Address: ___________________________________________________________________________________
City: _____________________________________________ State: ___________ Zip: __________________
C. Telephone No: __________________________ E-mail Address: ______________________________________
III. SITE INFORMATION:
A. Construction Site Address: ____________________________________________________________________
City: ____________________________________________ State: ____________ Zip: __________________
B. Parcel ID Number: ______/______/______/__________________/______/______
C. Incorporated: Unincorporated: _________________________________________________
D. Affected Water Body: _______________________________________________________________________
E. Previous Permits: __________________________________________________________________________
F. Date applicant assumed property ownership: ____________________________________________________
month/year
G. Obstructions: (Dogs, Fences, etc.) _____________________________________________________________
H. Attach 8 ½” X 11” vicinity map showing specific project location.
I. All other information pursuant to Section 166-328, Pinellas County Code, as needed.
J. For projects requiring a public hearing, attach a copy of the complete legal description.
Application # ____________________________
(OFFICIAL USE ONLY)
IV. PROJECT DESCRIPTION:
A. Nature and Size of Project: ___________________________________________________________________
_________________________________________________________________________________________
__________________________________________________________ Square Feet: ___________________
B. Variance: Yes No
Amount in variance: Length: ____________ Width: ____________
Setbacks: Left: _______________ Right: ____________
Other: ____________________________________________________________________________________
NOTE: It is the applicant’s responsibility to clearly demonstrate that any requested variances are consistent with
the variance criteria of Section 166-291 of the Pinellas County Code. The applicant must demonstrate that a
literal enforcement of the regulations would result in an extreme hardship due to the unique nature of the project
and the applicant’s property. The hardship must not be created by action(s) of the project owner(s). The
granting of the variance must be in harmony with the general intent of the regulations and not infringe upon the
property rights of others. The variance requested must be the minimum possible to allow for the reasonable use
of the applicant’s property. Should the applicant fail to demonstrate that any variance request is consistent with
the criteria outlined in the regulations, staff cannot recommend approval of the application.
V. CONTRACTOR INFORMATION:
I, ______________________________________________________________________, a certified contractor,
state that the dock has not been constructed and that it will be built in compliance with all requirements and
standards set forth in the Pinellas County Code, and in accordance with the attached drawings which accurately
represent all the information required to be furnished. In the event that this dock is not built in accordance with
the permit or the information furnished is not correct, I agree to either remove the dock or correct the deficiency.
Signed: ______________________________________________________ Cert No.: ____________________
Company Name: _________________________________________ Telephone No: ____________________
City: _____________________________________________ State: ___________ Zip: _________________
E-mail Address: ____________________________________________________________________________
VI. OWNER’S SIGNATURE:
I hereby apply for a permit to do the above work and state that the same will be done according to the map or plan
attached hereto and made a part hereof, and agree to abide by the criteria of the Pinellas County Code for such
construction and, if said construction is within the corporate limits of a municipality, to first secure approval from
said municipality. I further state that said construction will be maintained in a safe condition at all times, should
this application be approved, that I am the legal owner of the upland from which I herein propose to construct the
improvements, and that the above stated agent/contractor may act as my representative. I understand that I, not
Pinellas County, am responsible for the accuracy of the information provided as part of this application and that it
is my responsibility to obtain any necessary permits and approvals applicable for the proposed activities on either
private or sovereign owned submerged land.
____________________ _________________________________________________________________
Date Legal Owner’s Signature
PRIVATE DOCK
Application # ____________________________
(OFFICIAL USE ONLY)
MHW
MLW
BOTTOM
Profile View
ENG. SCALE: 1” =
TOTAL SQUARE FEET __________
NEW SQUARE FEET __________
WATERWAY WIDTH __________
WATERFRONT WIDTH __________
N
Plan View
(applicant and adjacent docks)
SHORELINE
The undersigned does not object to the proposed dock and requested variances as drawn in the space provided above.
Left Owner Right Owner
Signature Date Signature Date
Municipality Approval Water and Navigation Approval
VARIANCE REQUEST FORM
Application # ____________________________
(OFFICIAL USE ONLY)
Left Lot Owner’s Name ____________________________________________________________________________
Mailing Address ___________________________________________________ Zip _____________________
I certify that I am the owner of Lot _____ which adjoins the property owned by the applicant who proposes to construct
a dock at the following address:
________________________________________________________________________________________________
I have seen the plans of the proposed structure(s) along with any requested variances (see Section IV.B of the
application) and: DO OBJECT DO NOT OBJECT to the proposed construction.
OWNER’S SIGNATURE: _______________________________________________ Date ____________________
NOTARY:
STATE OF FLORIDA, PINELLAS COUNTY, BEFORE ME, the undersigned authority, personally appeared
_____________________________________, well known to me, or who provided a valid Florida Driver’s License to
be the person who executed the foregoing instrument and that he/she acknowledged to me, under oath, that he/she
signed the same freely and voluntarily for the purposes expressed therein.
Witness my hand and official seal this __________ day of ___________________________________, 20 _________
__________________________________________
Notary Public
My commission expires: ______________________
Right Lot Owner’s Name ___________________________________________________________________________
Mailing Address ___________________________________________________ Zip _____________________
I certify that I am the owner of Lot _____ which adjoins the property owned by the applicant who proposes to construct
a dock at the following address:
________________________________________________________________________________________________
I have seen the plans of the proposed structure(s) along with any requested variances (see Section IV.B of the
application) and: DO OBJECT DO NOT OBJECT to the proposed construction.
OWNER’S SIGNATURE: _______________________________________________ Date ____________________
NOTARY:
STATE OF FLORIDA, PINELLAS COUNTY, BEFORE ME, the undersigned authority, personally appeared
_____________________________________, well known to me, or who provided a valid Florida Driver’s License to
be the person who executed the foregoing instrument and that he/she acknowledged to me, under oath, that he/she
signed the same freely and voluntarily for the purposes expressed therein.
Witness my hand and official seal this __________ day of ___________________________________, 20 _________
__________________________________________
Notary Public
My commission expires: ______________________
Application # ____________________________
(OFFICIAL USE ONLY)
DISCLOSURE FORM
In order to alleviate any potential conflict of interest with Pinellas County staff, it is required that the County be
provided with a listing of PERSONS being party to a trust, corporation, or partnership, as well as anyone who may have
beneficial interest in the application which would be affected by any decision rendered by the County (attach additional
sheets if necessary).
A. PROPERTY OWNERS:
Name: ___________________________________ Name: ___________________________________
Address: _________________________________ Address: _________________________________
_________________________________ _________________________________
Name: ___________________________________ Name: ___________________________________
Address: _________________________________ Address: _________________________________
_________________________________ _________________________________
B. REPRESENTATIVES:
Name: ___________________________________ Name: ___________________________________
Address: _________________________________ Address: _________________________________
_________________________________ _________________________________
Name: ___________________________________ Name: ___________________________________
Address: _________________________________ Address: _________________________________
_________________________________ _________________________________
C. OTHER PERSONS HAVING OWNERSHIP INTEREST IN THE SUBJECT PROPERTY:
Interest is: contingent absolute
Name: _______________________________________ specific interest held: ___________________
__________________________________________________________________________________
D. DOES A CONTRACT FOR SALE EXIST FOR THE SUBJECT PROPERTY? YES NO
If so, the contract is: contingent absolute
Name of parties to the contract: ________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
E. DOES AN OPTION TO PURCHASE EXIST FOR THE SUBJECT PROPERTY? YES NO
Name of parties to the option: ____________________________________________________________
F. OWNER’S SIGNATURE:
I hereby certify that the information stated above is complete, accurate, and true to the best of my
knowledge.
X_______________________________________________ Date _______________________________
Consent to Use State-Owned Submerged Lands
DO YOU LIVE OR DO BUSINESS ON THE WATER?
If so, you may need authorization to use the lands under the water from the owners of those lands. This authorization is
in addition to any city, county, Florida Department of Environmental Protection, U.S. Army Corps of Engineers, or
Water Management District permit.
WHAT LANDS ARE WE TALKING ABOUT AND WHO OWNS THEM?
Sovereign submerged lands are all those submerged lands waterward of the ordinary or mean high water line under
navigable fresh and salt water bodies. The Governor and Cabinet, sitting as the Board of Trustees of the Internal
Improvement Trust Fund, hold title to all of those lands below navigable waters which have not been previously
conveyed into private ownership. Portions of these submerged lands have been designated as “aquatic preserves” and
because of their unique biological, aesthetic or scientific value, they are held and managed to a higher degree of care.
Since the State owns these lands, both public and private entities must obtain consent to use them.
WHY IS CONSENT NECESSARY AND BY WHAT AUTHORITY IS IT REQUIRED?
These lands are held in trust for the use and benefit of the people of the State, as set forth in the State Constitution;
therefore, the private use of these lands must be balanced with the need to conserve and protect the scientific value and
beauty of those lands. The intent of the regulations is to ensure that all sovereign submerged lands are managed
primarily for the propagation of fish and wildlife, and public recreation. The legislative origins of the procedures
employed in the review of applications to use sovereignty submerged lands are contained within Chapters 253 and 258
of the Florida Statutes. These statutes are implemented through rules which are contained within Chapters 18-14, 18-
18, 18-20 and 18-21 of the Florida Administrative Code. It is important to contact the Department of Environmental
Protection before you use these lands.
WHAT TYPE OF ACTIVITIES REQUIRE AUTHORIZATION?
Uses that require authorization must be approved before they are conducted. The most commonly requested uses are
the construction of docks, the placement of riprap, dredging for access or channels, mangrove trimming, bridge and
utility crossings, and beach renourishment projects.
WHAT DO YOU HAVE TO DO AND IS THERE A FEE?
The form of consent that is required depends upon the type of activity that is proposed. Forms of consent include
letters, easements, use agreements, management agreements, and leases. The type of activity proposed also determines
the amount of fees; however, commercial uses will always require payment of fees.
WHAT HAPPENS IF YOU DO NOT RECEIVE AUTHORIZATION TO USE THESE
LANDS?
Alterations to, or structures discovered on, sovereignty submerged lands without authorization are subject to lease fees
in arrears, with interest, and fines. In some cases, removal of structures may also be required.
WHO DO YOU CONTACT TO INQUIRE ABOUT THE USE OF THESE LANDS?
The Department of Environmental Protection Division of State Lands field office listed below.
Department of Environmental Protection
Southwest District
13051 N. Telecom Parkway
Temple Terrace, FL 33637
Phone: (813) 632-7600
Fax: (813) 632-7665
PRIVATE
DOCK
Application#
----------
(OFFICIAL USE ONLY)
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MHW
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ENG.
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TOTAL
SQUARE
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WATERWAY
WIDTH
WATERFRONT
WIDTH
240
180'
60'
10 0
20
Plan
View
(applicant
and
adjacent docks) .
SAMPLE
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P/L
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undersigned
does
not
object to
the
proposed dock
and
requested variances as drawn in the space provided above.
Left
Owner
Right
Owner
Signature
Date
Signature
Date
Municipality
Aooroval
Water
and
Navii:;ation
Approval
O,WWOlar1/ENVMGMNT/PrM48 4126194
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PRIVATE DOCK PERMIT APPLICATION PINELLAS COUNTY WATER AND (Pinellas County Clerk of the Circuit Court and Comptroller)

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Completed 10 February 2021

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