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C I T Y O F P U Y A L L U P Engineering Services 333 S Meridian, Puyallup, WA 98371 Tel: (253) 864-4165 Fax: (253) 840-6678 www.cityofpuyallup.org CITY OF PUYALLUP ASSIGNMENT FOR NEW CONSTRUCTION PERMIT # SITE ADDRESS In lieu of a performance bond at the direction of the City of Puyallup for the proposed construction of we are holding funds in the amount of ) in Account Number for the sole purpose of completing the referenced construction to standards acceptable to the City of Puyallup. We have been instructed by that these funds are to be used for the sole purpose described above. In the event said principal fails to complete construction to standards acceptable to the City of Puyallup, said funds in Account Number will be made available to the City of Puyallup for the sole and specific purpose of completing the above described construction. Failure of the financial institution to hold the minimum required amount until released by the City of Puyallup would bind the financial institution for the amount owed, for legal fees and costs necessary to enforce collection of the assignment. Signed and dated at , WA, this day of , This authorization to remain in full force and effect until a written release is received from the City of Puyallup which shall be at the time the specified construction is completed to standards acceptable to the City of Puyallup. Company Financial Institution Principal or Agent (signature) Officer (signature) Address Address City State Zip City State Zip Telephone Number Telephone Number ---PAGE BREAK--- Page 2 of 2 PRINCIPAL OR AGENT STATE OF WASHINGTON ) ) ss COUNTY OF PIERCE ) On this day of before me the undersigned, a Notary Public in and for the State of Washington, duly commissioned and sworn, personally appeared to me, known to be the individual described in and who executed the foregoing instrument, and acknowledged to me that signed and sealed this said instrument as a free and voluntary act and deed for the uses and purposes therein mentioned. Given under my hand and official seal this day of Signature Notary Public in and for the State of Washington Residing at My commission expires FINANCIAL INSTITUTION STATE OF WASHINGTON ) ) ss COUNTY OF PIERCE ) On this day of before me, the undersigned, a Notary Public in and for the State of Washington, duly commissioned and sworn, personally appeared to me, known to be the of the corporation that executed the foregoing instrument and acknowledged the said instrument to be the free and voluntary act and deed of said corporation, for the uses and purposes therein mentioned, and on oath stated that is authorized to execute the said instrument and that the seal affixed is the corporate seal of said corporation. Given under my hand and official seal this day of Signature Notary Public in and for the State of Washington Residing at My commission expires