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Application for Permit to Construct a Public Improvement
TOWN OF ORCHARD PARK, NEW YORK
PIP # 2026-02
In Consideration of the granting of this permit the applicant agrees:
That work under this permut shall be started within 60 days from the date of appraval by the Town Board and shall be completed within | year from the date of approval thereof.
Upon satisfactory completion, testing and acceptance of the work by the Town Board, all improvements described under this application will be dedicated to the Town of Orchard Park
The applicant is familar with and will comply with the laws of the State of New York, the Ordinances of the Town of Orchard Park and all the rules and regulations as set forth in
the Town of Orchard Park Local Law 41-1982 and its amendments governing the construction of public improvements and that he shall notify the Town Engineer in advance of
of commencing any work under this permit.
To hold harmless the Town of Orchard Park, its districts, subdivisions, or its Agents or Employees from any liabilities of any kind arising out of the performance of the proposed
construction, activities of the Town Employees or Public in conaestion with the proposed consjtiction or con én site, and that all persons connected with the actual work
under this permit shall be duly covered by liability and workgrdin’s compensation nsurangs —
a L
Signature of Owner o SILA
7
oe
Address Maple Grove Hoidings LLC; 4747 Camp Road; Hamburg, New York 14075 Telephone 716-646-6555
Subscribed & Sworn to before me this ’ (have examined the foregoing Plans and Specifications submitted by the applicant
a day of ul Se 20 C.kg)., and hereby ceitiy that they are in compliance with the specifications and requirements
of the Town of Orchard Park fa
ribs
NOTARY
LO Zara
PUBFIC-ERIE COUNTY-NEW
A YORK TOWN
i.
ENGINEER
Beans
DATE
SEAL DANIEL JACKSON ¥
Notary Public State eels Pursuant to Town Board Resolution No.
Qualified in Erie Dated 20
My Cemmission Expires 09/4A804 and any stipulations thereit atiached, approval is hereby granted for a permit to be
issued for the construction of public improvements in the Town of Orchard Park
TOWN SUPERVISOR DATE
[SWPPP INSPECTION FEE T $0.00]
{ have examined the insurance certificate and the secures attached hereto and certify
PERMIT FEE $ 50.00 that they are valid in form and meet the requirements as set forth in
INSPECTION Local Law #1-(982
8% on first $100,000.00 $2,400.00
7% on next $100,000.00 $0.00 TOWN ATTORNEY DATE
6% on next $100,000.00 $0.00
5% on next $100,000.00 $0.00
4% on next $100,000.00 $0.00
3% on all over $500,000.00 $0.00 (have examined the foregoing application and certify that the required fees have been
TOTAL FEES $ 2,450.00 pad and by my signature | do hereby issue this permit to construct public mprovements
in the Town of Orchard Park
TOWN CLERK DATE
copies to: 1. Town Clerk 3. Town Attorney
2. Town Engineer 4. Applicant
PIP FORM Rear Yard Drainage 6-5-26 2