PCF #0035
  Revision Date 06/95

PALM BEACH COUNTY
PLANNING, ZONING AND BUILDING DEPARTMENT
BUILDING DIVISION
PERMIT CENTER
EASEMENT CONSENT FORM 

Please Note: Forms may be filled out, but you must print them and
deliver them to the Permit Center. On-Line submittal is not yet available.

 

To: 

 
Address: 

   

Address:   

City:  

 

State: 

 

Zip:  

Gentlemen:

I am the record title holder of property located at

I propose to apply for a permit from Palm Beach County to construct or install a 

in the

easement on my property, the legal description of this property being:

Lot Block

Subdivision or Metes & Bounds

In the event that you have no objections to this improvement, please complete this form.
I understand that your company will not be responsible in any way for repairs to, or replacement of, any portion of the above referenced improvement and that any removal or replacement of this improvement necessary for your use or access of this easement will be done at the expense of the property owner or their successors in interest.

 

Owner's Name

Owner's Signature

STATE OF FLORIDA
COUNTY OF PALM BEACH
  The foregoing instrument was acknowledged before me this by 
Date
, who is personally known to me or who has produced
  Name of Person Acknowledging
as identification and who did/did not take an oath.
Type of I.D.

SEAL

_______________________

(Signature of person taking
acknowledgement)		 (Name of officer taking acknowledgement
typed, printed or stamped)
(Title or rank) (Serial number, if any)

2300 N. Jog Road
West Palm Beach, Florida 33411
(561) 233-5130
(561) 233-5144 FAX

ADA Alternative Document
(561) 233-51000
PCF #0035 Rev 06/95

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