AIRSPACE OBSTRUCTION PERMIT APPLICATION State of Florida

Form 725-040-11
Aviation
OGC – 02/04
Page 1 of 2
Type or Print on this Form
State of Florida
FOR FDOT USE ONLY
AIRSPACE OBSTRUCTION PERMIT APPLICATION
Department of Transportation
FDOT Permit Number
- FLA -
1. Applicant (person proposing this action):
2. Applicant’s Representative (if other than #1):
Name:
Name:
Title:
Title:
Address 1:
Address 1:
Address 2:
Address 2:
City:
State:
Phone #:
City:
Zip:
State:
Phone #:
Fax #:
-
Zip:
Fax #:
E-mail:
E-mail:
3. Type: … Antenna Tower
… Building
… Antenna – Side Mount
… Power Line
… Pole
… Crane
4. Notification Requirements:
Is proposed site within an incorporated community? … Yes … No
… Traverse Way
If yes, have appropriate authorities been notified?
… Landfill
… Water Tank
… Other:
… Yes … No
City/county requiring building permit:
5. Site Elevation (AMSL):
Feet
6. Total Structure Height (AGL):
Feet
7. Overall Height (#8 + #9)(AMSL):
Feet
Name of local official:
Title:
Address 1:
Address 2:
8. Latitude:
°
‘
.
“N
City:
9. Longitude:
°
‘
.
“W
Phone #:
10. Datum:
… NAD 83
… NAD 27 … Other
Zip:
Fax #:
E-mail:
11. County:
12. Section:
Township:
Range:
13. Nearest Military & Public-Use Airport(s):
14. This application MUST be accompanied by ALL of the following attachments:
a)
A copy of FAA Form 7460-1, Notice of Proposed Construction or Alteration, filed with FAA.
b)
An Aeronautical Study or FAA document showing the determination issued in response to your Notice of Proposed Construction.
c)
A USGS 7.5 minute Quadrangle Map with the precise site marked and any certified survey.
d)
A scaled construction diagram showing the size and dimensions of the proposed construction.
e)
Zoning statement from the appropriate zoning agency showing this proposal will comply with local zoning regulations and any
f)
If the applicant is not the landowner, attach a copy of the authorization to construct or lease of land involved.
conditions which must be accomplished for such compliance.
The undersigned hereby requests an Airspace Obstruction Permit in accordance with Section 333.025, Florida Statutes.
I herby certify that all of the above statements made by me are true, complete and correct to the best of my knowledge.
Date
Typed or Printed Name of Applicant
Signature
Mail this application along with attachments to Airspace and Land Use Manager
Florida Department of Transportation, Aviation Office, 605 Suwannee Street, Mail Stop 46, Tallahassee, Florida, 32399-0450
Aviation Phone 850-414-4500, E-mail - [email protected]; http://www.dot.state.fl.us/aviation/
Form 725-040-11
Aviation
OGC 02/04
Page 2 of 2
State of Florida
Department of Transportation
INSTRUCTIONS FOR
AIRSPACE OBSTRUCTION PERMIT APPLICATION
PLEASE TYPE or PRINT
ITEM #1. Please include the name, address, phone and fax number, and e-mail address of a personal contact point as well as the company name.
ITEM #2. Please include the name, address, phone and fax number, and e-mail address of a personal contact point as well as the company name.
ITEM #3. Please indicate the type of structure. DO NOT LEAVE BLANK.
ITEM #4.
Please indicate whether the proposed construction will be located within the geographical boundaries of a municipality. If the answer is yes,
then indicate whether or not you have notified local officials of your proposal. In addition, please indicate if the city or county is requiring a
building permit as well as the local officials name address, phone and fax numbers, and e-mail address.
ITEM #5.
Enter the site elevation above mean sea level expressed in whole feet rounded to the nearest foot (e.g. 17' 3" rounds to 17', 17'6" rounds to
18'). This data should match the ground contour elevations for site depiction submitted under ITEM #14(c).
ITEM #6. Enter the total structure height above ground level in whole feet rounded to the next highest foot (e.g. 17'3" rounds to 18'). The total structure
height shall include any appurtenances mounted on top of the structure, such as antennas, obstruction lights, lightning rods, etc. If the structure
will be constructed in close proximity to an airport or runway, this measurement should be the highest point of the structure and should match
the data submitted to FAA on Form 7460-1.
ITEM #7. Enter the overall height above mean sea level, expressed in whole feet. This will be the total of ITEM #5 + ITEM #6.
ITEM #8. Latitude and longitude must be geographic coordinates, accurate to within the nearest second or to the nearest hundredth of a second if known.
and
ITEM #9.
This data, when plotted, should match the site depiction submitted under ITEM 14(c). The coordinates should match those submitted to the
FAA on Form 7460-1. If the coordinates provided on this application do not match those indicated on either FAA Form 7460-1 or the FAA
Aeronautical Study, FDOT will not be able to process your application.
ITEM #10. NAD 83 is preferred; however, latitude/longitude may be submitted in NAD 27. Also, in some geographic areas where NAD 27 and NAD 83 are
not available other datums may be used. It is important to know which datum is used. DO NOT LEAVE BLANK.
ITEM #11. Please indicate in which county the proposed structure will be constructed.
ITEM #12. The Section, Township and Range, usually associated with real property legal descriptions, can be found within the real property deed or lease
agreement.
ITEM #13. Enter the name of all public-use airports (or heliports) or military airports (or heliports) within ten (10) nautical miles of the proposed site.
ITEM #14. Lists required attached documents needed to process the application.
a.
Include a copy of FAA Form 7460-1, Notice of Proposed Construction or Alteration, filed with FAA.
b.
Include an Aeronautical Study or FAA document showing the determination issued in response to your Notice of Proposed Construction.
c.
Enter the relationship of the structure to roads, airports, prominent terrain, existing structures, etc. Attach an 8-1/2" X 11" non-reduced copy of
the appropriate 7.5 minute U.S. Geological Survey (USGS) Quadrangle Map MARKED WITH A PRECISE INDICATION OF THE SITE
LOCATION. To obtain maps, Contact USGC at 1-800-435-7627 or via Internet at "http://mapping.usgs.gov". If available, attach a copy of a
documented site survey with the surveyor's certification stating the amount of vertical and horizontal accuracy in feet.
d.
A scaled construction diagram showing the size and dimensions of the proposed construction.
e.
Zoning statement from the appropriate zoning agency showing this proposal will comply with local zoning regulations and any conditions which
must be accomplished for such compliance.
f.
If the applicant is not the landowner, attach a copy of the authorization to construct or lease of land involved in the applicant’s name.
Submitting a request for an Airspace Obstruction Permit Application with the Florida Department of Transportation does not relieve the
sponsor of this construction or alteration from complying with any other federal, state or local rules or regulations.
If you are not sure what other rules or regulations apply to your proposal, contact local zoning authorities.
Mail this application with attachments to Airspace and Land Use Manager
Florida Department of Transportation, Aviation Office, 605 Suwannee Street, Mail Stop 46, Tallahassee, Florida, 32399-0450
Aviation Office 850-414-4500; E-mail - [email protected]; http://www.dot.state.fl.us/aviation/