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REAUIE9 APPLICATIO|I FOR A gECOl.lD DRhGtl,AY(T-4.1a)
OR A COIJNTY AFPLICATIOhI FOR FACILITY PERI1IT (C 9A.2O9)
IF IN THE U69.
DATE OF APPLICATIOT.I
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UJOFK DE9CRlPTlChl,
IIloFK TO BE FEFFOFI,IED EY:lV'
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ADDRE59 q s3+L <1 PFIONE:
PPCEDURE FOR lNgFECTlOt l RE@tlE9T,
aALL 129--3163 (RECORDER ) STATE YOUR CrTy DE9TGNATED JOts N[J13=R, JOg ADDR=99;yPE CINSPEcTIA{ REAUESTED A{D III.IEN YOI.I IUILL tsE READY FOR INSPECTIA.I, CONTRACICI?9 OR OII,.IERg N,+IE lJ'{D
PHohlE NttrlBER REotlESTg RECEI\€D BEFoRE lzoo /tl tUlLL BE IIADE TllE gAmE DAY, REaJE9TS trlER1zoo
AH IJJILL BE I1ADE TI.{E NEXT UJORKII.{3 DAY
EXIgTI}\IG EUILDtN6 PEB1IT NO. ( IF APFI-ICAtsLE )
*YOI,JR CITY JoB No. rsf 9l C;c1 1ttgEE BOOK
gIDETUALK / DRI\GI!,AY
r.OR ALL CO}.ICRETE PAVING TUITHIN
THE STREET RIGHT OF [UAY, TO BE
F1ADE AFTER AL EXCAVATINC
15 COI-IPLETE AID FORI'1 I]JORK
A}.ID 9IIE-BAsE I1AIERIAL 19
IN PLACE
CU@ / APPROACH APRoh,l'
AFTER rc815 A= ER=CTED
BUT PRIOR TO POURING
C,oNCRETE.
FEE9: SIDEIUALKg
TOTA FEffIIT FEE:
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COt.filERICAL DRIVEIIJAYg gHALL
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I i.{A\.E CAREFTJLLY EX,$1INED TI-.I= COI'IPLETED APPLICATION FOR PER.1I T. AND DO I-{ER=BY C=RiIFY TH/.T ALLIhFORrIATICAI }..IEREON 19 TRUE A\D CORRECT , AND I R]RT}]ER CERTIFY TI]AT A\Y AI.ID ALL II.OR< P=RFO31ED5I]ALL BE DONE IN ACCORDANCE IUITI{ TH=ORDINA\CE5 OF Ti{E CITY G 9PRI\I/JFI=LD, AD THE LAU9 oF TI-iESTATE ff OR=GON PERTAINING TO TI-]E I,IJORK DEgCRISED I{EREIN, AND THAT NO OCCUPAI.ICY U|I-L 3E HAD=OF A{Y IUITI{OJT PE R.1I95IOhI G TI]= BUILDINC DIVISION. I FURTHER CERTIFY TI{AT ONLY CONTRACT oR5u}.lo ARE rN COtlPLt IUITH OR9 1OI@>> TUILL BE Ug=D ON TI{I9 PROJECT,
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