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OFFICIAL USE ONLY
Permit No: Pood
Date:
Permit Fee Paid:
Issued By:
FLOODPLAIN DEVELOPMENT APPLICATION
70WNN OF oRCHA PARK
Site NEERING
reject “HEN rtion Location and Acreage) on425 devel {to |lmwo00 R?,
“THUS “Teeth-
3. Contractor (Name and Address)
PhoneNo. fg me Pm Re |
I me MRA ist ME cml BH2.L
4, Permit Fees: . F5C@ aragaae MAN Sce bho
$150 plus ($75 per acre or fractional part thereof) a aly lr 7d
$50 plus (2% of the Construction Cost) aS
Engineering Department will determine total fees upon submission of design package.
5. Site Improvement Bond:
Surety Corporation Name:
es
Bond Amount: * LOO
($2,000 per acre or fractional part thereof)
In consideration of the grant of this permit, the undersigned agrees as follows:
1. Refer to and fill out the attached Floodplain Development Permit Application forms as a part of this permit.
2. Work under this permit shall be started within sixty (60) days from the date of approval thereof.
Work under this permit shall be completed within one (1) year from the date of the approval
thereof. Any request for extension shall be addressed in writing to the Town Board of Orchard
Park.
3. The undersigned guarantees that all persons connected with the actual work under this permit
are duly covered by Liability and Workman's Compensation Insurance and the State, County
and Town shall be held harmless on accaunt thereof of the undersigned.
4, The undersigned hereby agrees to hold harmless the Town of Orchard Park, its Districts,
Subdivisions, or its agents or employees from ail liability of any kind arising out of the
performance of the proposed construction, activities of Town employees or the public in
connection with the proposed construction or construction site.
5. Working hours: 7:00AM to 6:00PM NO SUNDAY OPERATION
| have examined the foregoing application and agree to the terms set forth in this application
and do hereby certify that the required permit fee as established by the Town Board of Orchard
Park, New York has been paid.
Signature of Applicant: _\. eee
FloodplainDevelopment Permit Application 4