Application for Letter of Service Availability and/or Utility ... - FGUA

FLORIDA
GOVERNMENTAL UTILITY AUTHORITY
APPLICATION
FOR COMMERCIALL SERVICEE AVAILABILITY (FORM A)
Effective October 1, 2012 the following fees are
associated with a Commercial Service Availability Request
Utility Availability Map: $75 Letter of Utility Location Availability: $25 Letter of Utility Location Availability and Locate Map: $100
Please return the completed application
package to: Janelle Kusiolek, Project Coordinator: JKUSIOLEK@GOVMSERV.COMM
OR
℅ FGUA Operations Office
280 Wekiva
Springs Road, Suite 2000
Longwood, FL 32779
Phone: 407-629-6900
0
Fax: 407-629-6963
Providing the required information expedites the review process and enables a response within 10-working
days.
SECTION 1.
DO
YOU NEED UTILITY
LOCATES
By completing Section 1 of the application, you will be provided with approximate utility locations in the vicinity of the
listed property. The fee for the Location Map is $75. Should you need a project specific Letter of Availability, please
complete Sections 1 & 2.
1) Property Information: *This information is available on the county property appraiser’s website*
a) PROPERTY ID (Folio/STRAP
NO.):_______ ___________ ________________________________________
b) PROPERTY PHYSICAL ADDRESS:_______
____________ ________________________________________
_______________________________________________________________________________________
2) ATTACH
a location/ vicinity map with the completed application
3) Provide
contact information:
Name:____ _______________________________________ Date: ____________________________________
Company Name: _________________________________ Title:__________
______________________________
Address (including city, state and zip
code):____ ___________________________________________________
Email:____ ________________________________________ Telephone: _______________________________
Contact information must be provided
for all inquiries
FORM A - REV10.22.12
Page 1 of 3

SECTION 2.
DO YOU NEED A FORMAL LETTER OF AVAILABILITY
By completing Sections 1 & 2 of the application, you will be provided with approximate utility locations in
the vicinity of the listed property and a formal LOA. The fee for the LOA & Location Map is $100. The
following information is required if further permitting with FGUA is desired (i.e. if project is
contemplated for construction).
4) Name and address of PROPERTY OWNER (developer):
a) NAME and COMPANY NAME (if applicable):
______________________________________________________________
______________________________________________________________
b) MAILING ADDRESS (including city, state and zip code):
______________________________________________________________
______________________________________________________________
c) PHONE NUMBER and EMAIL ADDRESS:
______________________________________________________________
5) Service requested: Water Wastewater Reclaim Fire Protection
6) Project Information:
a) PROJECT NAME: ______________________________________________________________
b) PROPOSED USAGE (i.e. retail, medical, offices, salon, etc.)____________________________
c) SIZE (square footage): _________________________________________________________
d) PHASES (if applicable): _________________________________________________________
e) ESTIMATED DATE SERVICE IS REQUIRED: __________________________________________
f) Is the property currently platted _____ (YES) ______ (NO) If NO; do you intend to plat the
project upon completion of construction ____ (YES) _____(NO)
g) Will you be conveying an easement to the FGUA for the utility facilities to be accepted by FGUA
____(YES) _____(NO)
h) Will you be constructing the utility facilities to be accepted by FGUA in an existing Public right of way
or Utility Easement ____(YES) _____(NO)
7) Engineer’s estimate of average daily flows on an annual basis:
WATER: ______________________ GPD
RECLAIMED WATER: ____________GPD
WASTEWATER: _____________________GPD
FIRE PROTECTION:__________________GPD
FORM A - REV10.22.12 Page 2 of 3

Effective October 1, 2012 the following fees are associated with a Commercial Service Availability Request
Utility Availability Map (Section 1 – Map Only): $75
Letter of Utility Location Availability (Section 2 – Letter Only): $25
(This option can be used only if a Utility Availability Map has previously been issued)
Letter of Utility Location Availability and Locate Map (Sections 1 & 2 – Letter and Map): $100
Payment of the application fee can be submitted via check to:
OR
Florida Governmental Utility Authority
℅ Janelle Kusiolek, Project Coordinator
280 Wekiva Springs Road, Suite 2000
Longwood, FL 32779
Complete the following Credit Card Authorization Form and return it with your application.
All information will remain confidential.
*There will be a convenience fee of $1.50 associated with each credit card transaction*
Credit Card Type: ______Visa _____Mastercard _____Discover
*please note we do not accept American Express cards*
Cardholder Name:__________________________________________________ (as it appears on the card)
Credit Card Number:____________________________________________________________________________
Expiration Date (month/year):____________________________ 3 Digit Security Code (on the back of the card):______________________
Billing Address (as it appears on the card statement):____________________________________________________________________________
___________________________________________________________________________________________________
City, State and ZIP Code
I authorize Florida Governmental Utility Authority (FGUA) to process a one (1) time credit card payment in the amount
of $___________to my credit card provided herein. I agree that I will pay for this purchase in accordance with the
cardholder agreement.
Signed:___________________________________________________
Printed Name:_____________________________________________
Date:_____________________________________________________
For Office Use Only
System: Consolidated Golden Gate Lehigh Acres Lindrick Mad Hatter North Ft. Myers Pasco
Payment Processed:________________________(date)
By:_____________________________________(name)
Property Address: _____________________________________ Project Name: _________________________________
FORM A - REV10.22.12 Page 3 of 3