UNTY ORIN GOVERNMENT APPLICATION TO CONSTRUCT A DOCK. Name: Mail or Deliver To: SECTION 1 OWNER(S) OF THE LAND

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1 ORIN UNTY GOVERNMENT rlori A APPLICATION TO CONSTRUCT A DOCK (In Accordance with Orange County Code Chapter 15, Article IX, Orange County Code) Mail or Deliver To: Orange County Environmental Protection Division 800 Mercy Drive, Suite 4 Orlando, Florida (407) , Fax (407) **Filing fee of $ payable to The Beard of Coamtv Commissitmenc** '-'-' 1-7o.3s fee role Appeals Variatioest $4f;3.114" SECTION 1 OWNER(S) OF THE LAND Name: Robert ZIatkiss Title and Company: American Seminole County Investments, LLC Address: 3911 Orange Lake Drive City: Orlando state: Florida Zip: Telephone and Fax: (407) RZIatkiss@aolcorn ENTITY TO RECEIVE PERMIT (IF OTHER THAN OWNER), Name: N/A Title and Company: Address: City: State: Zip: Telephone and Fax: AGENT/CONSULTANT AUTHORIZED TO SECURE PERMIT Name: Sheila Cichra Title and Company: President, Streamline Permitting, Inc. Address: 2154 Oak Beach -Boulevard City: Sebring state: FL Zip: Telephone and Fax: (407) CONTRACTOR (IF DIFFERENT FROM AGENT) Name: Title and Company: Address: shellacichraagmailcom City: State: Zip: Telephone and Fax: Dark ComorizetionAppikwitars Revised 7131/13 Page 1 of

2 SECTION 2 - GENERAL INFORMATION Street Address: 4097 Conway Place Circle Tax Parcel ID _ 30 _ Legal Description: Meets and bounds - see attached (.4 r vey Name of water body: Lake Conway Normal High Water Elevation (NHWE): 755s. 9 0 i. Is the proposed dock? Please check one: 4/ Private Semi-Private Public What is the width of the shoreline (in linear feet), as measured at the NHWE? /6. 2 ci feet. What is the size of proposed terminal platform? 3 square feet. [See Chapter 15; Article IX; Section (b)] Areyou reaueztin g a valiance? s,/ Yes No 1--- lt-4.3 octi i,v LA _ 5 C r.r 3(,, 5- c?, 7z4. Are you requesting a waiver?.y0 Yea No \_/).i._ 3, - I.2 I, ( 0) ) If yes, provide section Number: a (example! ) and describe the nature of the variance and/or waiver request: keqvt-est 17 ( 5e-t1.4c4- q <l c '_ 2 1 fc tza (.4i A / r a_ Cl r titik.'e r -c 1 (4 /re" 70 f.le tt-ex ck. 4 /,s-,:,, r. r q Lk rs 6-- c t r r p,,,, ('la f--, 0 f (-1 3,..5 r: ft i?i /icy( d -P- N e a 71-6 coed , ft, Note appliattions fora waiver and/or variance from the boat clock ordinance will require (h completion of a separzne waiver and/or variant* application and may require additional fees. If you have questions, please call ETD for assistance. Brief Description of proposed work; Y I )(1o 1 duck 3 'x l 1", I, 6 -I 3 s / y 1 Y- 2cfr byc., ti-ko (,k 5 e Are there docks on the abutting properties? 4/ Yes Are there any access restrictions to the property (locked gate/loose dogs): No No REQUIRED ATTACHMENT{S) CHECKLIST: Satisfactor), evidence of titio.e c_m_lanpie: copy of properly deed), Documentation showing riparian rights for the parcel. A copy of a survey, to scale, of the real property which accurately depicts current conditions. Four (4) copies tof a site plan depicting the exact location of the proposed dock, and shall include the following: An arrow indicating the northerly direction of the scale to which the sketch or drawing was prepared. The name of the water body upon which the proposed dock structure or renovation is to he located The exact distance between the shoreline and a permanent object or construction. The exact setback distance from adjacent property lines and projected property lines to all portions of the &ICE The floor and roof elevations of the proposed or existing dock. The current water depth at the end of the proposed or existing dock, and at all proposed mooring locations. The length of the proposed or existing dock, as measured from the NHWE to the point most waterward of the NHWE. Dock Caostnietion Arrplication Revised 7/31/13 Faze 2 of 5

3 The NHWE as established by the county shown property survey as field verified by a professional surveyor. O The location of any conservation easement areas and wetlands within twenty feet from any portion of the dock A description of vegetation types identified occurring within twenty foot from any portion of the dock The location of any lifts, hoists, mooring pilings and mooring areas A mitigation plan offsetting adverse impacts to the conservation easement areas or wetlands (if applicable) A description of sedimentation and erosion control measures used during construction and/or repair of the dock AGENT AUTHORIZATION FORM PERSON AUTHORIZING ACCESS TO THE PROPERTY MUST COMPLETE THE FOLLOWING: I either own the property described in this application or I have legal authority to allow access to the property and I consent to any site visit on the property by agents or personnel from Orange County, Florida necessary for the review and inspection of the proposed project specified in this application. I authorize these agents or personnel to enter the property as many times as may be necessary to make such review and inspection. Further, I agree to provide entry to the project site for such agents or personnel to monitor permitted work if a permit is granted. Robert Zlatkiss Typed/Printed Name aft/ Date Corporate Title (if applicable) By signing and submitting this application form, I am applying for the permit 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 conducted prior to approval is a violation. I understand that this application and any permit issued pursuant thereto, floes not.relieve me of any obligation for obtaining y other =mired federal, Atgeatategginglit rmit rior to commencement of construction. I understand that Orange County will snake no representation as to the proposed dock's impact on navigability or safety. For that reason, understand that it may be advisable for me to consult with an expert in navigability and safety issues, I agree, or I agree on behalf of my corporation, to operate and maintain the permitted system unless the permitting agency authorizes transfer of the permit to a responsible operation entity; I understand that knowingly making any false statements or ----relreemw-iiittlis application is a violation of Sections & , Orange County Code, Typed/Printed Name of Applicant Sheila Cichra Signature of Applicant/Agent Date President, Streamline Permitting, Inc. Corporate Title (if applicable) Dock Construction ANgication Revised 7/31113 Pap 3 of 5

4 Name and Address of adjacent property owners: Name: John A. Moore Address: 4091 Conway Place Circle SECTION 3 City: Orlando State FL Zip Name: Conway Place Homeowner's Association of Orange County, Inc. Address: P.O. Box City: Orlando State_ FL zip NOTICE TO APPLICANTS: The proposed dock structure may require a permit from either the Florida Department a Environmental Protection or the applicable Water Management District. In addition to public regulations which Orange County enforces ; be advised that there may be other private restrictions or approval requirements that will affect your ability to erect this structure. Please review your deed restrictions and/or consult with your Homeowner's Association or Architectural Review Board. Dock Con vtruction Application Revived 7/31/13 Pazo 4 of 5

5 AGENT AUTHORIZATION FORM FOR PROJECTS LOCATED IN ORANGE COUNTY, FLORIDA I/WE, (PRINT PROPERTY OWNER NAME) Robert Ziatkiss AS THE OWNERS) OF THE REAL PROPERTY DESCRIBED AS FOLLOWS, GOVERNMENT 4097 Conway Place. Circle DO HEREBY FLORIDA AUTHORIZE TO ACT AS MY/OUR AGENT (PRINT AGENT'S NAME), Sheila Cichra, TO EXECUTE ANY PETITIONS OR OTHER DOCUMENTS NECESSARY TO AFFECT THE APPLICATION APPROVAL REQUESTED AND MORE SPECIFICALLY DESCRIBED AS FOLLOWS, Boat Dock Permit, AND TO APPEAR ON MY/OUR BEHALF BEFORE ANY ADMINISTRATIVE OR LEGISLATIVE BODY IN THE COUNTY CONSIDERING THIS APPLICATION AND TO ACT IN ALL RESPECTS AS OUR AGENT IN MATTERS PERTAINING TO THE APPLICATION. Date: // CM 1i. Date: Date: Date: STATE OF FLORIDA COUNTY OF ORANGE oignazu of Property owner Signature of Property Owner Signature of Property Owner Signature of Property Owner /Aile7A5T- Print Name ProRerty Owner Print Name Property Owner Print Name Property Owner Print Name Property Owner I certify that on 91/ ti before me, R 084-qt ZIfIrk,s an officer duly authorized by the State of Florida and in t e county mentioned above, to take acknowledgements, personally appeared to me known to be the_person described in this instrument or to have produced as evidence, aridiroho has acknowledged before me-wat he or she executed the instrument and did / did not take an oath. Witness my hand and official seal in the county an state s in the year z ed ab5nre on the tc day of 11., /,./ e '''' SUSAN J GORDON State of Florida My Comm. Expires Nov 14, 2014 Commission # EE Signature of hbflitary Public N4itay 101'140 My Commission Expires: / I // // Legal DescriptIon(s) or Parcel Identification Number(s) are required: PARCEL ID th LEGAL DESCRIPTION: Meets and bounds - see attached.

6 RELATIONSHIP DISCLOSURE FORM For use with development related items except applications in which the County is the principal or primary applicant This form shall be submitted to the department processing your application prior to the development-related item being considered for review and/or approval by Orange County. In the event any information provided on this form should change, the applicant(s) should file an amended form on or before the date of project consideration before the appropriate board or body. IS THE APPLICANT OR ANY PERSON INVOLVED WITH YOUR PROJECT: A RELATIVE OR BUSINESS ASSOCIATE OF THE MAYOR OR MEMBER OF THE BCC? AN EMPLOYER OF THE MAYOR OR MEMBER OF THE BCC? IS ANY PERSON WITH A BENEFICIAL INTEREST IN THE OUTCOME OF THIS MATTER A BUSINESS ASSOCIATE OF THE MAYOR OR MEMBER OF THE BCC? Please complete table below: Applicant/Principal Developer Property Owner Consultants/Attorney Business Associate Relative Employer Beneficial interest in the outcome YES/NO YE /NO YE /NO YES N YES/NO YES/NO YES/NO YES/NO YES/JO YES/NO; YES/NO i YES/NO YES/ 0 ) YE NO i YE /NO 1 YE NO --i If you responded yes to any of the above questions, please state with whom and explain the relationship: Dock Construction Application Revised Page 6 of 9

7 Page 2 of 2 ORIGINAL SIGNATURE AND NOTARIZATION REQUIRED I hereby certify that information provided in this relationship disclosure form is true and correct based on my knowledge and belief. If any of this information changes, I further acknowledge and agree to amend this relationship disclosure form prior to any meeting at which the above-referenced project is scheduled to be heard. In accordance with s , Florida Statutes, I understand and acknowledge that whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor in the second degree, punishable as provided in s or s , Florida Statutes. 4tiC67( Signature Print Name and Title of Person completing this form: Date: / 2 c.(// Te S4,44 Cf-,-, Business Address (Street/P.O. Box, City and Zip Code): 2 /S- 0 c k era c,4 vd, t f:c &r;)-7, F 2 3 r73- Business Phone (yo 7) y Cj / Facsimile ( ) STATE OF FLORIDA COUNTY OF O tt ti GE : I certify that on 7 t, 2 (71//-7/, before me, Rc- r c, an officer duly authorized by the State of Florida, and in the county mentioned above, to take acknowledgements, perso _IA ev", to me known to be the person described in this instrument or to have produced, as evidence, and who has acknowledged before me that he or she executed the instrument and did / did not take an oath. Witness my hand and official seal in the county and state stated above on the y, in the year 0-0. day of Notary Public State of Florida rs t 4rAZ eon ion EE of fta- Expires 03103/2017 Signature of Notary Public Notary Public for the State of Florida My Commission Expires: 3 /3 h 7 Dock Construction Application Revised Page 7 of 9

8 ORANGE COUNTY SPECIFIC PROJECT EXPENDITURE REPORT This form should be completed in full and filed with all application submittals. This form shall remain cumulative ** File any amendment with the department processing your application. Part I Please complete the following: Name and Address of Principal or Principal's Authorized_Agent: 2(5-6( (De4-, (,'( Name and Address of Lobbyist, consultants, contractors, if any: f4c/lai / N/19 rire7a/--4 /q S- Part II Expenditures: An "expenditure" is defined to mean a payment, distribution, loan, advance, reimbursement, deposit, or anything of value made by a lobbyist or principal for the purpose of lobbying, as this term is defined in section 2-351, Orange County Code. The term "expenditure" does not include contributions or expenditures reported pursuant to chapter 106, FS, or federal election law, campaign-related personal services provided without compensation by individuals volunteering their time, any other contribution or expenditure made by or to a political party, or any other contribution or expenditure made by an organization that is exempt from taxation under 26 U.S.C. s. 527 or s. 501(c)(4). (s , FS) The following is a complete list of all lobbying expenditures incurred by the principal or his/her authorized agent, his/her lobbyist, and/or his/her contractors, if applicable, expended in connection with the above-referenced project or issue: Date of Expenditure Name of Payee Description of Expenditure Amount Expended If continued on a separate sheet, please check here Total Expenditures this Report: $ 6 0 Date of this Report: 7 /2 1// $ $ $ $ $ $ C C, c`j Dock Construction Application Revised Page 8 of 9

9 Page 2 of 2 I hereby certify that information provided in this specific project expenditure report is true and correct based on my knowledge and belief. I further acknowledge and agree to comply with the requirement of section of the Orange County code to amend this specific project expenditure report for any additional expenditure incurred related to this project prior to the scheduled Board of County Commissioner meeting. In accordance with s , Florida Statutes, I understand and acknowledge that whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor in the second degree, punishable as provided in s or s , Florida Statutes. Date: 7/ (-(7( y f/ Signature of n Principal or( Principal's Authorized Agent* (check appropriate box) STATE OF FLORIDA COUNTY OF Og-fr4 cr I certify that on,1-c-t /,/ Y, 20 I, before me, Ke- re,, an officer duly authorized by the State of Florida and in the county mentioned above, to take acknowledgements, personally appeared 1Z1 c c,, tome_known te be tbe--persan_described in this instrument or to have produced, as evidence, and who has acknowledged r'e--rrhat or he or she executed the instrument and did I did not take an oath. Witness my hand and official seal in the county and state stated above on the 2Y17`day of, in the year 2 ( 1. e "NI Or liaeaSOA Florida Renea Anderson My Commission EE Expires 03/03/2017 Signature of Notary Public Notary Public for the State of Florida My Commission Expires: 3 l 3 // *If form is signed by the Principal's Authorized Agent, please attach the completed Agent Authorization form. Dock Construction Application Revised Page 9 of 9

10 ORAN 1E C UNTI. GOVERNMENT I' I. ORID A APPLICATION TO CONSTRUCT A BOAT DOCK APPLICATION FOR WAIVER (Pursuant to Orange County Code, Chapter 15, Article IX, Section (a)(2)) Mail or Orange County Environmental Protection Division Deliver To: 800 Mercy Drive, Suite 4 Orlando, Florida (407) , Fax (407) Sheila Cichra on behalf of Robert Zlatkiss (if applicable) pursuant to Orange County Code Cha ter 15, Article IX, Section (a)(2) am requesting a waiver to section (choose and circle from the following: (b), (a) and (a)) of the Orange County Dock Construction Ordinance. 1. Describe how this waiver would not negatively impact the environment: The boathouse that we are proposing is a minimally sized terminal platform. It will be much smaller than the average boathouse or terminal platform. 2. Describe the effect of the proposed waiver on abutting shoreline owners: The proposed structure will not adversly affect the adjacent property owners' view or navigability. It is being located parallel to the adjacent boat ramp, so it will not be a navigation hazard and the vegetation in the back yard on the other adjacent property is located such that the boathouse will be minimally visible. The environmental protection officer and the board may require of the applicant information necessary to carry out the purposes of this article. By signing and submitting this application form, I am applying for a waiver to the Section indicated of the Orange County Dock Construction Ordinance 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 conducted prior to approval is a violation. I understand that this application and any permit issued pursuant thereto, does not relieve me of any obligation for obtaining any other required federal, state, or local permits prior to commencement of construction. I understand that knowingly making any false statements or representation in this application is a violation of Sections & , Orange County Code. Name of Applicant: Sheila Cichra Signature of Appli Agent,' Date: 7/24/14 Corporate Title (if applicable): rrns f f l %).-kc c. Application for Boat Dock Waiver Rev

11 C UNTY GO\ ERNMENT L OR ID.1 APPLICATION TO CONSTRUCT A DOCK APPLICATION FOR VARIANCE Mail or Orange County Environmental Protection Division Deliver To: 800 Mercy Drive, Suite 4 Orlando, Florida (407) , Fax (407) (Pursuant to Orange County Code, Chapter 15, Article IX, Section (a)(1)) **Enclose a check for $ payable to The Board of County Commissioners** I Sheila Cichra on behalf of Robert Zlatkiss (if applicable) pursuant to Orange County Code Chapter 15, Article IX, Section (a)(1) am requesting a variance to section (a) of the Orange County Dock Construction Ordinance. 1. Describe how strict compliance with the provisions from which a variance is sought would impose a unique and unnecessary hardship on the applicant (the hardship cannot be self-imposed): The property boundaries pie dramatically creating a very small space in which one could build a dock. Also, a boat ramp was built without EPD or DEP clearance on the adjacent property and severely encroaches on this parcel's riparian rights. 2. Describe the effect of the proposed variance on abutting shoreline owners: The proposed structure will not adversly affect the adjacent property owners' view or navigability. It is being located parallel to the adjacent boat ramp, so it will not be a navigation hazard and the vegetation in the back yard on the other adjacent property is located such that the boathouse will be minimally visible. Notice to the Applicant: The environmental protection officer, environmental protection commission and the Board of County Commissioners may require additional information necessary to carry out the purposes of this article. A variance application may receive an approval or approval with conditions when such variance: (1) would not be contrary to the public interest; (2) where, owing to special conditions, compliance with the provisions herein would impose an unnecessary hardship on the permit applicant; (3) that the hardship is not self-imposed; and (4) the granting of the variance would not be contrary to the intent and purpose of this article. By signing and submitting this application form, I am applying for a variance to the Orange County Dock Construction Ordinance 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 conducted prior to approval is a violation. I understand that this application and any permit issued pursuant thereto, does not relieve me of any obligation for obtaining any other required federal, state, or local permits prior to commencement of construction. I understand that knowingly making any false statements or representation in this application is a violation of Sections & , Orange County Code. Name of Applicant: Sheila Cichr /-",(T7 Signature of Applican4gen -) L4 Date: 7/23/14 Corporate Title (if applicable): President, Streamline Permitting, Inc. Rev. 7/31/2013

12 ZLATKISS FLOOR PLAN 4097 CONWAY PLACE CIRCLE 2' 24' 14' X 28' UPPER DECK 40' 17 LAKE CONWAY 1 'd l Ct r ri" Gr NHWE ' 4'

13 XVNI.9 AVMNOO 3)011 06'98 3MHN NM -71 xdw 11V NOld 3102l13 30Vld AVAANO3 L6017 NOLIVA313 SSINIV1Z

14 NOTES: - BEARINGS BASED ON THE CENTERLINE OF CONWAY PLACE CIRCLE AS BEING S56'01'24"E. LOT NO UNDERGROUND UTILITIES WERE LOCATED. - 0 REPRESENTS SET 5/8" IRON #4671 UNLESS OTHERWISE NOTED - ELEVATIONS BASED ON ORANGE COUNTY BENCHMARK L ELEVATION = ' NAVD 1988 DATUM. r 1" = 20' N N "W 57.97' (MEASURED) N69'55'19"W (DESCRIBED) NORMAL Hag WATER UNE ELEVATION ' TOCA7ED PR XIMATE LING 14' POINT OF BEGINNING YEAR FLOOD LINE ELEVATION 88.00' LOCATED 7/10/24 18' ENCROACHMENT,--24' 2' ENCROACHMENT CONCRETI RAM EDGE OF WATER ELEVATION IN 84.22' LOCATED 7/10/2014 LAKE CONWAY ZLATKISS SITE PLAN DETAIL 4097 CONWAY PLACE CIRCLE

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