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Ln-,,~~I~te~ `~- /~-~ ~ JOB # 96- 07~'~~ , / <br />V <br />MARION COUNTY PUBLIC WORI<S <br />Operations Division ~;f'~..' Q~' ~ <br />cv > <br />JOB NUMBER FORM <br />~: ~_Si <br />Date _ `~ / /- `~ ( <br />IS THIS WORK BILLABLE? NO <br />i~ <br />Description of work (~'~~~~. <br />~ f ~3 ~'~ ~ <br />~~ ~ Le~e 1f~ <br />~ <br />Name I-~t~;~,-1-;~~ 11'I,,., <br />i~ <br />Address /'}'~r~o n _~'_r'u.. ~ ~t.. ~, ~~~CI-~~~ ~u ~ . <br />City. State, Zip ltiG' l~ic~~-~ ~Tf! N~i ~!!? ~~- %~) /~`'-/FI; <br />Phone _=j~ ~~ _- ~ ~- <br />The undeisigned unde~stands that comp/etion of this iequest lo~ p~ivaie wo~k is contingent <br />upon [he avai/abi/ity o/ ioad mafnlenance pe~sonne/ and equipment. County ~oad opeiations <br />have p~io~ity. The undersigned /urther ag~ees to pay for a/l /aboi mate~ia/s, and equipment <br />requi~ed to complete the wo~k ~equested, by the lOth of ihe month fo0owiny invoicing. The <br />apPlicant furthe~ agrees to hold Ma~ion County ha~m/ess f~om any c/aims a~ising out o1 the <br />wo~k. <br />Signature of Applicant <br />Authorized By <br />IOperations Supt. or Assi. ons. s~~i.1 <br />DATE COMPLETED _ - I ~ ~ ~~ <br />COMPLETED BY j ,~;,~~~ <br />Labor/Cquipment/Materials U~sed <br />ES <br />I '' G . j <br />~ `. ! - ~i~" i~ ~~ <br />:" <br />,.. • , <br />< tVPinVllorm~abnumb Lm -- <br />J~~nc 2G. 199G 1 0~~ <br />