Easement Consent & Removal Agreement-FILLABLE form (8-2016)
City of Boynton Beach Building Division 100 East Boynton Beach Blvd, PO Box 310, Boynton Beach FL 33425-0310 Phone: (561) 742-6350 Fax: (561) 742-6357 S:\Development\Building\\Forms&Templates\Easemen
t Consent-Removal Agreement & Easement Holders (7/04, 8/05, 8/06, 9/07, 12/07, 12/08, 3/09, 5/13, 10/14, 8/16) EASEMENT CONSENT To: _____________________________________________ Name
of easement holder Address: _____________________________________________ _____________________________________________ _____________________________________________ Gentlemen: I am
the record titleholder of property located at ____________________________________. I propose to apply for a permit from the City of Boynton Beach to construct or install a __________________________
____ in the ____________________ easement on my property, legally described as: Lot _______________ Block _____________ Subdivision ____________________________ or Metes & Bounds ____________________
________________________________________ ____________________________________________________________________________ Please complete the section below indicating your approval or disapproval
of this work. I understand that you will not be responsible 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 to this easement will be performed at my expense or my successors in interest. ___________________________________ Owner's Signature
& Date _________________________ Owner’s Phone # ___________________________________ Owner's Signature & Date ACKNOWLEDGEMENT: I/We (agree) (do not agree) to the proposed improvement
under the circumstances described on pages 3 and 4 of this document. _________________________________________________________________________________ Name of easement holder(s) By:
____________________________________ Title: ______________________________ Date: __________________________________ (1 of 4) 1 of 4
City of Boynton Beach Building Division 100 East Boynton Beach Blvd, PO Box 310, Boynton Beach FL 33425-0310 Phone: (561) 742-6350 Fax: (561) 742-6357 S:\Development\Building\\Forms&Templates\Easemen
t Consent-Removal Agreement & Easement Holders (7/04, 8/05, 8/06, 9/07, 12/07, 12/08, 3/09, 5/13, 10/14, 8/16) EASEMENT HOLDERS To assist you in identifying potential easement holders,
the following list is being provided. THIS LIST IS NOT INCLUSIVE AND OTHER ENTITIES MAY HAVE EASEMENT RIGHTS. It is the applicant’s responsibility to identify all easement holders. NOTE:
A copy of a survey must be provided with each consent form when submitting to the easement holder. CABLE: GAS: Comcast Florida Public Utilities Fax: 561-454-5899 Phone: 561-832-0872
Wade_Hagerty@cable.comcast.com Fax: 561-838-1769 M-F 8AM-5PM M-F 8AM-5PM 7201 N Federal Hwy Attn: Engineering Boca Raton, FL 33487 401 S Dixie Hwy. Attn: Wade Hagerty West Palm Beach
FL 33401 Comcast PBC Construction Dept. (Mailing: PO Box 3395, W P B FL 33402-3395 (Allow 1 week for return fax or email) include self-addressed, stamped envelope) *Do NOT send request
via U.S. mail E-mail: engineering-wpb@fpuc.com ELECTRIC: TELEPHONE: Florida Power & Light Company BellSouth Telephone /AT&T Phone: 742-2000 Main Contact: 561-357-6410 Fax: 742-2016 Fax:
305-552-5979 M-F 7:30AM-4PM Email: G30576@att.com 9329 S Military Trail M-F 8AM-5PM Boynton Beach FL 33436 -2901 120 North K Street (www.fpl.com) Lake Worth, FL 33460 Attn: Robert Lowen
Note: No longer accepting walk-ins or postal mailed requests WATER/SEWAGE: City of Boynton Beach Utilities Dept. Phone: 742-6400 Email: easementconsent@bbfl.us M-F 8:00AM-4:00PM 124
E Woolbright Road 2 of 4 Boynton Beach FL 33426-6040
City of Boynton Beach Building Division 100 East Boynton Beach Blvd, PO Box 310, Boynton Beach FL 33425-0310 Phone: (561) 742-6350 Fax: (561) 742-6357 S:\Development\Building\\Forms&Templates\Easemen
t Consent-Removal Agreement & Easement Holders (7/04, 8/05, 8/06, 9/07, 12/07, 12/08, 3/09, 5/13, 10/14, 8/16) REMOVAL AGREEMENT DATE: PERMIT NO:________________ WHEREAS, ____________________________
___ (hereinafter referred to as “Owner(s)” (Print) is/are desirous of construction or installing a ____________________________________in a portion of the ________________________________
easement on my/our property, the legal description of this property being as follows: Lot _______________ Block ______________ Subdivision ________________________ or Metes & Bounds
________________________________________________________ ________________________________________________________________________ WHEREAS, the Owner(s) does/do covenant that they are
the fee simple owner(s) of the property; and WHEREAS, the above is to be erected for the use and enjoyment or proper functioning of the property and special aesthetics; NOW, THEREFORE,
in the consideration of the City of Boynton Beach (“City”) not immediately enforcing its rights or the rights of any others, now existing or which may in the future exist, against the
Owner(s) or the property, the Owner(s) hereby agree(s) with the City to remove, at no expense to the City, the Easement holders, or the beneficiaries of the easement, the above described
improvement from the property, within thirty (30) days of written notice addressed to them or their successors in interest, at: ADDRESS: ______________________________________________________________
_ _________________________________________________________________________ notifying them that said improvement is inconsistent with the use of the Easement. It is agreed by the Owner(s)
that the improvement shall be as depicted on Exhibit “A” and filed with the City of Boynton Beach Building Division, and that no other construction shall be in effect in said Easement.
It is agreed by the parties, hereto, that this Declaration will be recorded at the expense of the Owner(s) in the Official Records of Palm Beach County, Florida and that this Declaration
shall be a covenant running with the land and be binding upon the heirs, personal representatives, grantees, assigns and successors in interest of the Owner(s). Owner(s) shall immediately
remove the improvement permitted herein in the event that the City or Owner(s), or both, are challenged with respect to the City’s authority to authorize the placement of said improvement
in the Easement or a claim of damages is made as a result of the placement of said improvement in the Easement. In the event that the City and/or Owner(s) are challenged with 3 of 4
City of Boynton Beach Building Division 100 East Boynton Beach Blvd, PO Box 310, Boynton Beach FL 33425-0310 Phone: (561) 742-6350 Fax: (561) 742-6357 S:\Development\Building\\Forms&Templates\Easemen
t Consent-Removal Agreement & Easement Holders (7/04, 8/05, 8/06, 9/07, 12/07, 12/08, 3/09, 5/13, 10/14, 8/16) respect to the placement of said improvement in the Easement, or a claim
for damages is made as a result of the placement of said improvement in the Easement, Owner(s) shall indemnify, defend, and save the City harmless against and from said challenge. Upon
the vacation, abandonment or discontinuance of the Easement, this Declaration shall immediately and automatically terminate and be of no further force and effect. SIGNED, SEALED, EXECUTED
AND ACKNOWLEDGED on this _________________ day of ___________________, ________. WITNESS: ________________________________ ___________________________________ Owner’s Signature ______________________
__________ ___________________________________ Owner’s Signature ________________________________ Owner’s Phone # STATE OF FLORIDA COUNTY OF PALM BEACH The foregoing instrument was acknowledged
before me this ___________________ day of _________________________, ________, by ___________________________________ (Name of Person Acknowledging) who is personally known to me or
who has produced ______________________________ (Type of ID) as identification and who did/did not take an oath. (Signature of person taking acknowledgement) (Name of Officer taking
acknowledgement typed, printed or stamped) (Title or rank) (Serial number, if any) SEAL 4 of 4