HomeMy WebLinkAbout18100029 Right Of Way Permit0
RIGHT-OF-WAY PERMIT
PERMIT NUMBER: lo 0
Dery
!TODAY'S DATE: ✓ ESTIMATED DATE OF WORK: APPLICANT (Person doing the Work)
COMPANY:
1AUL)RESS:
PHONE:
CUSTOMER:
ADDRESS:
PHONE:
f2EMAIL PERMIT TO:
L -\T1 I F Ic , r
C
51-1 —1 L- Z -I
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ADDRESS F PROJECT:
D 1p So 71
D R Z,
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E C TION OF WORK (check all that apply)
JROAD SORE 7
CONSTRUCTION ENTRANCE —7 DRIVEWAY REPLACEMENT
STREET CUT LANE CLOSURE
DESCRIPTION:
ROAD CLOSURE
TYPE OF SURFACE CUT (if applicable),
5 IN PAVEMENT REQUIRE BOARD OF pUBLIC
*IVOTE: OPEN CUT
USE OF' HEAVY EQUIPMENT WORI(S (BPW) APPROVAL -
jDRAWqqC YES
G ATTACHED NO
YES
NOTE 0 NO
CSN REVERSE 'OF THIS PERMIT, PROVIDE NAMES AND CONTACTS OF ALL SUB�CONTRACTORS INVOLVED
. . . . . . . . . . . . . . . .
,SURETY'OND 112asesee Item #1 of I I I e Rj
BONDING COMPANY: /Vay Conditions, 0/
BONDING NUMBER: IV`
EXPIRATION DATE,
As appl/Cq�'Tt ...... . ....
or this Right -of, r
Permit, 1 uO derstand and agree to
ail Of the specifications and
Cond't1ons listed,9n the attached sheet.
(APPlican s Sijtiat - ure)
(Privt KI—C
PERMIT GRANTED BY: K—;4
COMMENTS:
�-v
(City
DATE ISSUED:
REPAIR WORK INSPE
I have inspected the repair of the above CTED AND APPROVED
right-of-way and find it to be cclmpleteIy satisfacto,y,
(City Inspector)
(Date Released)