Financial Responsibility Form - signedFinancial Responsibility Form
The owner understands that all Village -incurred professional fees and expenses associated with
the processing of this application request are ultimately the responsibility of the owner. A security
deposit shall be deposited in an interest-bearing account with any accrued interest to be retained by the
Village of North Palm Beach.
The owner and/or designee shall be invoiced on a monthly basis for professional fees such as, but not
limited to, consultant engineering services, legal services, advertising costs, and/or any other costs
attributable to the processing of the permit for which the Village incurred during the previous month. The
owner and/or designee shall reimburse the Village within thirty (30) days from date of invoice. If payment
is not received, the Village may utilize the security deposit for re -imbursement purposes. All activities
related to the pending permit(s) will cease until any outstanding invoices are paid.
The owner/designee further understands that transfer of this responsibility shall require a
completed form, signed and notarized by the responsible party, and delivered to the Community
Development Department if the name and/or address of the responsible party changes at anytime
duri, g,the applic lon review process.
ate
Property Control Number
DE JAAGa�lf1 L�fJIIUX 1pj(�k_ �LoAkil As C6
D 0
y n Desi n t
Acceptance Signature
1 NOTARY ACKNOWLEDGEMENT
STATE OF AX_
COUNTY OF �OfyM KIL96_Q )
hereby celtify that the foregoing instrunjent wasacknowledged before me this W day of
201-O► by 'Uo i n . He or she is personally known to me or
ha oro uced _ as identification.
public signature
Printed name
State of 47-\(Nt7AA at -large My Commission expires:
P
JOYCEMO i
MY COMMISSION # GG 249760
*;
EXPIRES: August 26.2W
�'r. OF Fti�P'
Bonded Thm Notary Putge Undawn1 rs