HomeMy WebLinkAbout15060025 Storm Water Permitf2IGHT-O�'-WAY PERMIT
PET2MIT NO: s�/c.'f�ls�—/
PERi`vIIT ISSOI:D TOR �440RK �bVIT'H7N CtTY RIGH7'-C?F-�VAY ANDIOR�CONS"CIICTION �iVT'RANCE OR
CO`7STRUCTION TRAF'FIC P'RO:Y17'F3E RIGHT-OF-�VAY
1Vote: Open cuts in pavement require Board of Public Works (BPti� Appro4-ai
ADDRESS OF �VORK: � �,�� �
�t'�tf�� ,��t�
DESCRIPTION t�F WORK (check all that apply): Road Bare CQnstruction Entrance
Street Cut Driveway Replacement_ Lane Closure _ Road Closure` Other
USE OF HLAVY EQUIPIvIENT (�� or no): IF YES, TYPE"OP HEAVY EQUIPl�1ENT (Bobcaf or
_�
laraer) TO BE USET�: � j y7 � �c� �( C��
TODAY'S DATE: ��"� �J "� J� ESTIMATED DATE OF �l'QRK=
TYPE dF SURf�AGE TO BE CUT (ifapplicable)._
r�FPL3CAitiT'S N,�iVIE (Person doingthe wz�rk):
Address�.� � � � � t"� v� n � e � � �; i`
r u c`�' i «� �non�: �3 d 7' `��' `'1 � �`�=x �' .�
I -r' ( r -
WFIO IS APPLICANT DOING Fti'f3I2K FOR: Name: c��� �`, � �',�y�{�;�t � t' �,
�/ � ._ _�--��
Address: ��� l�l. ��'J1b�,����redvti �� Phone: ���i`j-N ?d� ��%Cic>
DRAtiUINGATTAGHED ye� orno} ������
N�OTE: ON IZEVEsPSE SID� OF 7'HIS P�,I2MIT, P120VII)E NAI4IES AND CONTACTS OF ALL SUB-
CON`l�Rt1GTC)RS TO BE INVOLVED IN ON-SIT� �VORK ON THIS PROSfiCT. ,,�����
`` 1211�
StIR�TY BOND: Please see Item #� 1 of the Right of 1Vay�Conditions ����; ,S ��
f � ��
BONDIiv�G COY[PANY: l,,.d BO\iDING r� ��= __� �- �� �%
��`�-� ��`��'1�
�t.� �appiiccrnt for this righd-r�f-tivay�ermit, I arre�er•simzd arz ag�f� to all t/re s�ecif cntions an�l conditions
lfstec! ur: tlze ttttcached sheel: /J ,.� „�'` ;,�'", ��
t�PPlicant's Signatirre)
PER�SIT GRANI'�D t3Y: ---- �" �'t,. �'`�� '--- '!�__ ,'� �''�M..
(G� fhcial) (llaE�.Issued)
I2�I'AIR �l`ORIi Ii�'Sl'PCT'PI3 �Ni) AI'P120�'I;D
1 fia�•e ins�ectecl the� r�pair of�the above ri�ht-�f-�vay ancl find it to be c�mpletcl�� safisfactory.
(City Tnspec t�ir}
(Datc Relzas�d)
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