Application for Textile Recycling Collection Bin City of Jacksonville, Florida Planning and Development Department

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1 Date Submitted: TRCB Application Number: Date Filed: Application for Textile Recycling Collection Bin City of Jacksonville, Florida Planning and Development Department Please type or print in ink. For additional information or questions regarding this application, please contact the Planning and Development Department at (904) For Official Use Only Current Zoning District: Council District: Invoice / CR number: Current Land Use Category: Planning District: Notice of Violation(s): Overlay: Amount of Fee: Zoning Asst. Initials: PROPERTY INFORMATION for bin location 1. Bin Property Address: 2. Real Estate Number: 3. Land Area (Acres): 4. Service Area: 5. Benefitting foundation or charitable organization: OPERATOR S INFORMATION (Bin contact person) 6. Name: Address (including city, state, zip): 9. Preferred Telephone: Page 1 of 4 P L A N N I N G A N D D E V E L O P M E N T D E P A R T M E N T 214 N. Hogan Street, Suite 300 Jacksonville, FL Phone: Fax:

2 APPLICANT S INFORMATION (Permittee, if different from owner) 10. Name: Address (including city, state, zip): 13. Preferred Telephone: 14. Date of birth (if individual) or Entity formation 15. FEIN Number, if applicable: date: PARCEL / PROPERTY OWNER INFORMATION 16. Name: Address (including city, state, zip): 19. Preferred Telephone: ATTACHMENTS The following attachments must accompany each copy of the application. Bin construction details including materials, bin floor area, bin height, and bin sensors Site Plan (to scale) with bin location detail at 1 =10, to include the following: Bin location, and setbacks with dimensions of distance from public rights-of-way, abutting properties, and residential zoning districts. Bin maintenance and emptying schedule Agent Authorization if application is made by any person other than the property owner (Exhibit B) Copy of Local Business Tax Receipt Signage 2 bin sides only maximum 5 sf per side. If recycling bin for other than non-profit provide statement 2 below bin chute Permittee s name is not a charitable organization. The materials deposited in this bin are recycled and sold for profit and are not tax deductible - lettering shall be at least 2 high Photographs of bin Appropriate notarized authorizations (bin owner; bin permittee; and parcel owner) FEES Permit fee: $75.00, payable to Tax Collector Application for annual permit renewal: $75.00 Page 2 of 3 P L A N N I N G A N D D E V E L O P M E N T D E P A R T M E N T 214 N. Hogan Street, Suite 300 Jacksonville, FL Phone: Fax:

3 SUBMITTAL This application must be typed or printed in ink and submitted along with three (3) copies for a total of four (4) applications. Each application must include all required attachments. Submit applications to: Planning and Development Department, Zoning Administrator 214 North Hogan Street, 2 nd Floor (904) Page 3 of 3 P L A N N I N G A N D D E V E L O P M E N T D E P A R T M E N T 214 N. Hogan Street, Suite 300 Jacksonville, FL Phone: Fax:

4 Application for Textile Recycling Collection Bin PARCEL OWNER - AUTHORIZATION AFFIDAVIT City of Jacksonville Planning and Development Department 214 North Hogan Street, Zoning Section 2 nd Floor, Ed Ball Building Address: RE#(s): I hereby certify that I have read and understand the information contained in this application, that I am the owner or authorized agent for the owner with authority to make this application, and that all of the information contained in this application, including the attachments, is true and correct to the best of my knowledge. Responsibility and Liability of Bin Owner, Bin Permittee, and Parcel Owner. It shall be the responsibility of the bin owner, the bin permittee and the parcel owner identified in the permit to comply with the provisions of Section , Zoning Code. Failure to comply with the provisions of this Section shall constitute a violation of the Zoning Code, and shall subject the violator to the penalties provided herein. I hereby certify that I am the owner of the parcel described above and have given permission for the bin owner to operate a textile recycling bin on my property, provided that the bin owner maintains a lawful City permit at all times to operate the bin. I agree to allow the City to enter the premises to remove a textile recycling bin, its contents and any recycling materials that are placed near the bin, if the removal provisions of Section , Zoning Code are triggered. Parcel Owner Print name: Signature: Date: Sworn to and subscribed and acknowledged before me this day of 20, by, who is personally known to me or who has produced as identification and who took an oath.

5 Application for Textile Recycling Collection Bin BIN OWNER - AUTHORIZATION AFFIDAVIT City of Jacksonville Planning and Development Department 214 North Hogan Street, Zoning Section 2 nd Floor, Ed Ball Building Address: RE#(s): I hereby certify that I have read and understand the information contained in this application, that I am the owner or authorized agent for the owner with authority to make this application, and that all of the information contained in this application, including the attachments, is true and correct to the best of my knowledge. Responsibility and Liability of Bin Owner, Bin Permittee, and Parcel Owner. It shall be the responsibility of the bin owner, the bin permittee and the parcel owner identified in the permit to comply with the provisions of Section , Zoning Code. Failure to comply with the provisions of this Section shall constitute a violation of the Zoning Code, and shall subject the violator to the penalties provided herein. As bin owner, I hereby certify that I shall maintain a lawful City permit at all times to operate the bin. I acknowledge that the City may enter the premises to remove a textile recycling bin, its contents and any recycling materials that are placed near the bin, if the removal provisions of Section , Zoning Code are triggered. Bin Owner Print name: Signature: Date: Sworn to and subscribed and acknowledged before me this day of 20, by, who is personally known to me or who has produced as identification and who took an oath.

6 Application for Textile Recycling Collection Bin BIN PERMITTEE - AUTHORIZATION AFFIDAVIT City of Jacksonville Planning and Development Department 214 North Hogan Street, Zoning Section 2 nd Floor, Ed Ball Building Address: RE#(s): I hereby certify that I have read and understand the information contained in this application, that I am the owner or authorized agent for the owner with authority to make this application, and that all of the information contained in this application, including the attachments, is true and correct to the best of my knowledge. Responsibility and Liability of Bin Owner, Bin Permittee, and Parcel Owner. It shall be the responsibility of the bin owner, the bin permittee and the parcel owner identified in the permit to comply with the provisions of Section , Zoning Code. Failure to comply with the provisions of this Section shall constitute a violation of the Zoning Code, and shall subject the violator to the penalties provided herein. As bin permittee, I hereby certify that I shall maintain a lawful City permit at all times to operate the bin. I acknowledge that the City may enter the premises to remove a textile recycling bin, its contents and any recycling materials that are placed near the bin, if the removal provisions of Section , Zoning Code are triggered. Bin Permittee Print name: Signature: Date: Sworn to and subscribed and acknowledged before me this day of 20, by, who is personally known to me or who has produced as identification and who took an oath.

7 EXHIBIT B Agent Authorization Limited Liability Company (LLC) Date: City of Jacksonville Planning and Development Department 214 North Hogan Street, Suite 300, Re: Agent Authorization for the following site location in Jacksonville, Florida: Address: RE#(s): To Whom It May Concern: You are hereby advised that, as of, a Limited Liability Company organized under the laws of the state of, hereby certify that said LLC is the Owner of the property described in Exhibit 1. Said owner hereby authorizes and empowers to act as agent to file application(s) for for the above referenced property and in connection with such authorization to file such applications, papers, documents, requests and other matters necessary for such requested change as submitted to the Jacksonville Planning and Development Department. (signature) (print name) Sworn to and subscribed and acknowledged before me this day of 20, by, as, of, a Limited Liability Company, who is personally known to me or who has produced as identification and who took an oath. G:\JOINT\Applications\Exhibits\Agent Authorization Form LLC.docx

8 EXHIBIT B Agent Authorization - Individual Date: City of Jacksonville Planning and Development Department 214 North Hogan Street, Suite 300, Re: Agent Authorization for the following site location in Jacksonville, Florida: Address: RE#(s): To Whom it May Concern: You are hereby advised that, as of, hereby certify that said undersigned is the Owner of the property described in Exhibit 1. Said owner hereby authorizes and empowers to act as agent to file application(s) for for the above referenced property and in connection with such authorization to file such applications, papers, documents, requests and other matters necessary for such requested change as submitted to the Jacksonville Planning and Development Department. By Print Name: Sworn to and subscribed and acknowledged before me this day of 20, by, who is personally known to me or who has produced as identification and who took an oath. G:\JOINT\Applications\Exhibits\Agent Authorization Form Individual.docx

9 EXHIBIT B Agent Authorization General Partnership Date: City of Jacksonville Planning and Development Department 214 North Hogan Street, Suite 300, Re: Agent Authorization for the following site location in Jacksonville, Florida: Address: RE#(s): To Whom it May Concern: You are hereby advised that, as of, a general partnership organized under the laws of the state of, hereby certify that said general partnership is the Owner of the property described in Exhibit 1. Said owner hereby authorizes and empowers to act as agent to file application(s) for for the above referenced property and in connection with such authorization to file such applications, papers, documents, requests and other matters necessary for such requested change as submitted to the Jacksonville Planning and Development Department. (signature) (print name) Sworn to and subscribed and acknowledged before me this day of 20, by, as, of, a General Partnership, who is personally known to me or who has produced as identification and who took an oath. G:\JOINT\Applications\Exhibits\Agent Authorization Form Gen Partnership.docx

10 EXHIBIT B Agent Authorization - Corporation Date: City of Jacksonville Planning and Development Department 214 North Hogan Street, Suite 300, Re: Agent Authorization for the following site location in Jacksonville, Florida: Address: RE#(s): To Whom it May Concern: You are hereby advised that, as of, a corporation organized under the laws of the state of, hereby authorizes and empowers to act as agent to file application(s) for for the above referenced property and in connection with such authorization to file such applications, papers, documents, requests and other matters necessary for such requested change as submitted to the Jacksonville Planning and Development Department. (signature) (print name) Sworn to and subscribed and acknowledged before me this day of 20, by, as, of, a corporation, who is personally known to me or who has produced as identification and who took an oath. G:\JOINT\Applications\Exhibits\Agent Authorization Form Corporation.docx

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