Permit #: ________________________
Date Submitted:___________________
CITY OF PARKVILLE ▪ 8880 Clark Avenue ▪ Parkville, MO 64152 ▪ (816) 741-7676 ▪ FAX (816) 741-0013
Affidavit & Acknowledgement of
Existing Infrastructure Conditions & Repair Requirements
1. Property Description
Property Address: _____________________________________________________________
Plat #: _______ Lot#: ______ Subdivision: ________________________________________
2. Contact Information
Applicant / Permit Holder:
Name: _____________________________
Company: __________________________
Address:____________________________
___________________________________
Phone 1:____________________________
Phone 2:____________________________
Email:______________________________
Occ. License #: ______________________
Property owner(s) if other than applicant:
Name: _____________________________
Company: __________________________
Address: ___________________________
___________________________________
Phone 1: ___________________________
Phone 2: ___________________________
Email:______________________________
3. Acknowledgements
Per Parkville Municipal Code, Title V, Chapter 500, Section 500.050, care shall be taken to
protect all new and existing public infrastructure, including but not limited to curbs, sidewalks,
pavement, water mains, storm sewers, and sanitary sewers. Should such infrastructure
become damaged after issuance of a building permit, the damaged item(s) shall be repaired by
the permittee or owner following current city construction standards prior to issuance of a
Certificate of Occupancy.
In the event the permittee or owner believes any damage exists prior to the issuance of a
building permit, the permittee or owner is responsible for contacting Alan Schank, the
Director of Operations, at (913) 915-4156 prior to starting any construction for the
purposes of documenting any pre-existing damages. Any damage(s) found after the start of
construction will be required to be repaired by the permittee.
I, the undersigned, have read the referenced conditions herein and hereby certify and affirm by
my signature that I understand said conditions and agree to abide by the same. I further
understand that any violations from the provisions of said codes or conditions of approval
identified herein shall constitute cause for the retraction of this permit and enforcement and
penalties as prescribed by the Parkville Municipal Code shall be applied, including penalties not
exceeding a fine of five hundred dollars ($500.00) and costs, or imprisonment for a term not
exceeding ninety (90) days, or both such fine and imprisonment. I understand that each day in
which any violation exists shall constitute a separate offense. I further understand, this
agreement shall be binding upon the owner or his or her successors in title.
Signature:_________________________________________________ Date:_____________
Printed name:________________________ Title:__________________________________
Z:\Original Word Docs\Affidavit - existing conditions.doc
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Last Updated October 9, 2013
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