HomeMy Public PortalAbout5601 A & B WELLAND AVE_Grading__ APPLICATION FOR. GRADING P-E.RMIT
76AG41V-CEB070 18-75
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN ADDRESS �' / ,Q�✓+
AIDDRESS45 -7,A(I;e K/ LOCALITY
NUMBERS BLOCK NEAREST �y
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NUMBER DISTRICT�NNO. . MAP NO. STATE HWY. P, CE E BY
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OWNER USE ZONE'SPECIAL
MAIL CONDITIONS
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CITY 110. �
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ENGINEER �� �jfSE'AG.TNO
MAIL _J SURETY $ BN OND
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TEL. SURETY
CITY ®j�e1$ . NO. COMPANY
GRADIN A/ TEL. DATE RECD.
CONTRACTOR - NO. FILED BY }}}...
ADDRESS ' CASH RECD. DATE
DEPOSIT $: BY FILED
PROPOSED USE OF GRADED SITE(S) THIS IS A.LIMITED TIME PERMIT o
ALL WORK AUTHORIZED MUST BE COMPLETED BY
LL
1 TIME LIMIT: /d (o •-'7 z
EXTENDED TO: BY:
EXTENDED TO:
CHECK IF SUPERVI R 1 T�fi� �•I CTOR•�BT URE
INITIAL __dd
GRD. PREP. q
SIGNATURE COMPACTION •9/dr ` -
OF APPLICANT �
TEL. REPORT RECD.
ADDRESS ` � NO. ���3� SUP. ENGR•S.. r
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS CERT. RECD. -yf b� �' ,,,l1�Iyj, ,y(-
APPLICATION AND STATE T AT THE ABOVE IS ROUGH GRADING Ir
CORRECT
-AND.
AGREE TO CO LY TH ALL COUNTY APPROVAL (� j�` d
'ORDINANCES AND S E ULATING EXCA- PLANTING AND r
VATING AND-GRADII IRRIGATION Q
SUP. EN GR•S•. -
.SIGNATURE OF FINAL CERT.
PERMITTEE 6''� FINAL
AGENT FOR £C�e/ rlor/"G ` SURETY BOND•
RELEASED
ADDRESS ^ '� P.C. Fee$ / Permit Fee
CUBIC YDS.
HANDLED: Issuance Fee
M O x' _ Total Fee
PLAN CHECK VALIDATION CK. M.G. CI,,SHN N o PERMIT VALIDATION CK. M.O. CASH
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