Villages C PW-CN 920603~e,~O~Ctle$ eewn ~lle C~ i:~ ~p~.ll'$ pR A IN A G~ F.A ~1~ ]~]~T
i~ (~]:~i~ ~:~)W~,~ 0~1~ C~y'$ DRAINAGE EASEMENT
DRAINAGE EASEMENT
De~-iption of Work to be Done CII~ of (~fork: [] New I-IAddition
[-I Alteration [] Repair I-] Demolition
A~I of BuiMin~ in Square F~t
First Floor Garage
Second Floor Other
NOTICE
~fithln 180 days, ot ~.oosmgtlon on work
'~lyI at Iny limo ~ work k
1 btu~by c~tify that I have ~ ~md eximiaed
and coFrect. All l~OVhlons of bM and ordhonco8 ~ovemioj Ihls tyj~ of wor~ will
complied wilh whalha~ specified bcr~in or not. Thc grz~tlo~ of · peflnit do~ not
Sivo s~horlty lo violate or cnccl the pFovhlom of any oth~ federal, sate or local Jtw
re&,ukti~ construction o~ the i~formtnce of ~onstru~C~on.
Signature of ~ontflcior ne Authariz~d A~t Print Nome
Ek~u~ ~onu~o~ Plumbiaa ~onu~ctor M~dm~:al Contractor
of Work t
to be Performed /
GRAY AREA FOR OFFICE USE ONLY