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PERMITNo. 2026-02
Application for Permit to Construct a Public Improvement
TOWN OF ORCHARD PARK, NEW YORK
TO THE HONORABLE TOWN BOARD
TOWN OF ORCHARD PARK, NEW YORK
Application is hereby made for permission to construct:
State project name (name of subdivision, street, or other identifying location). Describe generally all contemplated work. List quantities, linear footage, etc. for all items checked.
Project Name Webster Road 3-Lot Block Subdivision Map Cover
No. of Sublots 3
[__]Paving and Curbing [~ |street Lighting
[x [Drainage . 392 Feet Rear Yard Drainage [Landscaping
[ |Sanitary Sewer [Jother
[| Waterline (LF & # Hyd's.) [other
The estimated cost of the improvement is {$30,000.00 |
Estimated cost of the improvement shall be determined by the Town Engineer. Qwner may submit copy of actual contract or other acceptable evidence for
veritication.
Contractor(s)
Address Telephone
Insurance Certificate No. Insurance Co.
The contractor shall fite with the Town Attorney certificates of proof of insurance with minimum coverage of 100\L:300M/100M liability and workmans compensation
containing standard notice of cancellation clause.
PERFORMANCE SECURITY $ 3,000.00
(check appropriate box)
Perf. Bond No. Bonding Co.
[_]cash Deposit Bank Cert. Check No.
Performance security shall be in the amount of 10% of the estimated cost of the work. It shall cemain in effect until such time as.a written release is granted by the Town.
Failure to comply with the provisions of this law or its amendments may result in forfeiture of the aforementioned security.
MAINTENANCE SECURITY $ 15,000.00
[ _|Maintenance Bond No. Bonding Co.
[ |cash Deposit Bank Cert, Check No.
Maintenance security shall be in the amount of 50% of the estimated cost of the work. It shall be in effect for a period of two years following acceptance of the completed
work by resolution of the Town of Orchard Park and shall be released only upon written authorization fom the Town.
[_]Escrow For: DateRevd Date Released
Amount:
[ |Escrow For: . Date Revd. Date Released
Amount:
[_]Escrow For: . DateRevd Date Released
Amount:
[ |Escrow For: . Date Revd. ne Date Released
Amount: :
PIP FORM Rear Yard Drainage 6-5-26 {