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PERMIT APPLICATION FOR GRADING PROJECT ADDRESS LAND OWNER ADDRESS PHONE CITY STATE ZIP CODE DESIGNATED AGENT ADDRESS PHONE CITY STATE ZIP CODE DATE OF PROJECT START DATE TO BE COMPLETED PROJECT TYPE: _____RESIDENTIAL _____MULTI-FAMILY _____COMMERCIAL _____INDUSTRIAL _____LAND BALANCING PROJECT DESCRIPTION SIZE OF EARTH MUST INCLUDE 2 COMPLETE SETS OF TOPOGRAPHICAL PLANS DRAWN AT A SCALE OF NOT LESS THAN ONE INCH EQUALS 50 FEET AND SHALL SHOW EXISTING AND PROPOSED GRADES AND TOPOGRAPHIC FEATURES PLAN PREPARER’S PHONE PERFORMANCE DEPOSIT AMOUNT REQUIRED _____CASH _____CERTIFIED CHECK _____IRREVOCABLE LETTER OF CREDIT _____SURETY BOND NAME OF SURETY COMPANY PHONE ADDRESS CITY/ST/ZIP ENGINEERING I (we) affirm that the above information is accurate and that I (we) will conduct the above described earth change in accordance with Part 91, Soil Erosion and Sedimentation Control of the Natural Resources and Environmental Protection Act, 1994 PAA 451, as amended, applicable local ordinances and the documents accompanying this application. LAND OWNER’S SIGNATURE DATE LAND OWNER’S NAME (PRINTED) DESIGNATED AGENT’S SIGNATURE * DATE DISIGNATED AGENT’S PRINTED NAME * AGENT MUST HAVE WRITTEN STATEMENT FROM LANDOWNER AUTHORIZING HIM/HER TO SECURE A PERMIT