DESCRIPTION OF REQUESTED VARIANCE (INCLUDE MANUAL/CODE AND ATTACHMENT REFERENCES) :
ALTERNATIVES TO REQUESTED VARIANCE (INCULDE WHY REQUESTED VARIANCE IS BETTER):
JOB NAME: / WSSC JOB NUMBER:
HOLD HARMLESS AGREEMENT
The Owner(s) shall defend, indemnify and save harmless the Commission from all suits, actions, and damages or costs of every name and description to which the Commission may be subject or put by reason of injury to persons (bodily injury, including death, or any personal injury) or property damage as a result of the granting this requested variance.
Owner’s Signature ______
Printed Name ______
Address ______
______
Phone ______eMail______
Engineer’s Signature ______
Printed Name ______
Address ______
______
Phone ______eMail______
FOR WSSC USE ONLY DATE RECEIVED: ______
ACTION TAKEN: Approved _____ Denied _____
EXPLANATION OF ACTION / SPECIAL CONDITIONS OF VARIANCE:
SIGNATURE: ______DATE: ______
Development Services Group Leader
INSTRUCTIONS FOR COMPLETING FORM
1. A single waiver is acceptable for projects with the same job number and different alpha suffixes (ex: DA1234Z05, DA1234A05, DA1234B05, DA1234C05 etc….)
2. In the same box with Job Number, list the Permit No. or On-Site Plan No. if applicable.
3. Must be detailed and complete.
4. Must be complete and convincing. Give details such as elevations, lengths, existing conditions, job related limitations, etcetera. Attach supporting documentation, (letters from County, MNCP+PC etc…) if this supports your request.
5. Applicable Plans, drawings, product literature, etcetera shall be attached.
6. The Applicant/Owner must sign the form. A plumber, builder’s field superintendent, etc. shall not sign as the agent.
7. The ‘Engineer’s’ signature is required.
8. The Variance form and supporting information must be uploaded into ePlan Review as a single PDF into the Documents Folder.
9. The results will be posted in the approved folder in ePlan review – whether it is approved or denied.
10. Please contact the Development Services Group at (301) 206-8650 if you have questions regarding this form.
T:\Forms\SEP\Phase 2\DESIGN REVIEW\Variance Request Form.doc
Last Saved: March 25, 2014
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