VILLAGE OF LIONS BAY

Park Bench Dedication Application Form

Applicant Name:                                                                                                                                                                 

Address:                                                                                                                                                                                               

Telephone:                                                                                            Fax:                                                                        

Select bench style:               James Sandison                                             Sanderson Concrete                 

                                                    ($1200.00)                                                       ($1500.00)

Select maintenance option:     Complete                                       Option A                                Option B                  

                                                                                                                (less $300.00)                        (less $500.00)

Total Cost to Applicant:                                    

Describe proposed location of bench:                                                                                                                            

Provide details of proposed wording on plaque:                                                                                                           

Authorized By:   Superintendent of Works:                                                    Administrator:                                     

Date Approved:                                                                   Date Bench Installed:                                                         

Date Agreement Expires:                                                   

Signature of Applicant:                                                                                      Date:                                                      

Comments: