d2-fax-order-form (1).pdf

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

FAX ORDER FORM

375-000-02

STATE HIGHWAY ENGINEER

02/13

Exempt Documents - Section 119.071(3) (b) Florida Statutes, provides:

Building plans, blueprints, schematic drawings, and diagrams, including draft, preliminary, and final formats, which depict the internal layout and structural elements of a building, arena, stadium, water treatment facility, or other structure owned or operated by an agency are exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution. This exemption applies to building plans, blueprints, schematic drawings, and diagrams, including draft, preliminary, and final formats, which depict the internal layout and structural elements of a building, arena, stadium, water treatment facility, or other structure owned or operated by an agency before, on, or after the effective date of this act. Information made exempt by this paragraph may be disclosed to another governmental entity if disclosure is necessary for the receiving entity to perform its duties and responsibilities; to a licensed architect, engineer, or contractor who is performing work on or related to the building, arena, stadium, water treatment facility, or other structure owned or operated by an agency; or upon a showing of good cause before a court of competent jurisdiction. The entities or persons receiving such information shall maintain the exempt status of the information.

Check one: Licensed Architect Engineer Contractor

Other: (please state nature of business)

Company/Entity Name:

Address:

Phone Number:

We accept VISA, MasterCard, Discover, and American Express

Credit Card Number: N/A Exp. Date:

Authorized by: Vendor No.: VF

Fax No.:

Ship to: (If different) Company Contact – Name

Street Address City State Zip

Ship to: (if different) Phone No. Fax No.

FDOT ships by UPS Ground or USPS. Allow 1-5 business days for delivery.

To Request Next Day Delivery Check Either: FedEx or UPS Provide Acct. No.

Letting Date Proposal Number

Or Financial Project Number

Plan/Specs & Bidding Document (Prime Contractor)

No. Sets of Plans/Specs

Only

No. Sets of Plans Only

No. Sets of Specs Only

District Contracts Administration Office: District 2 - Lake City Phone: 386-758-3778 Fax Number: 386-758-3791 Email Address: d2fixedcapitaloutlay@dot.state.fl.us

PS233BW

Highlight

375-000-02

STATE HIGHWAY ENGINEER

02/13

Letting Date Proposal Number

Or Financial Project Number

Plan/Specs & Bidding Document (Prime Contractor)

No. Sets of Plans/Specs

Only

No. Sets of Plans Only

No. Sets of Specs Only

Signature required for receipt of the above records.

I, personally, and/or as representative of the above entity, fully understand the exempt nature of the public records I am receiving and agree to maintain the exempt status of this information in accordance with Florida law.

Name of person receiving records:

(Printed)

Signature: Date:

Email:

Authorized by: Signature:

Printed Name

Date: