HomeMy WebLinkAboutROW PermitRIGHT-OF-WAY PERMIT
PERMIT NUMBER:
AY'S DATE: 10- 2&- 10 —ESTIMATED DATE OF WORK: Ow. �19
APPLICANT (Person doing the work) ty�-
COMPANY:
ADDRESS: llb2E2
PHONE: ?�jj gX;53-�-&6 EMAILPER191'ITTO:
CUSTOMER:
ADDRESS:
PHONE:
� 1 :] - - 5:32.77
ADDRESS OF PROJECT: I 14z] VNII,, Uu—
DESCRIPTION OF WORK (check all that apply)
ROAD BORE DRIVEWAY REPLACEMENT
CONSTRUCTION ENTRANCE LANE CLOSURE
STREET CUT ROAD CLOSURE
01 HER
DESCRIP-ION:
TYPE 01, SURFACE CUT (if applicable):
*NOTE: OPEN CUTS IN PAVEMENT REQUIRE BOARD OF PUBLIC WORKS (BPW) APPROVAL*
r i
USE OF HEAVY EQUIPMENT YES NO
DRAWING ATTACHED YES iL NO
*NOTE: ON REVERSE SIDE OF THIS PERMIT, PROVIDE NAMES AND CONTACTS OF ALL SUB -CONTRACTORS INVOLVED
SURETY BOND. Please see Item 41 of the Right -of -Way Conditions.
BONDING COMPANY:
BONDING NUMBER:
EXPIRATION DATE: i n - 7-:25 - I
applicant for this Right-ofWayPermit, I understand and agree to a!/ of the specifications and
conditions 1i rqd on the attached 'sheet,
r 34��
TApplicant's Signature) (Print Name)
-1,
PERMIT GRANTED BY: DATE ISSUED:
"lCity
COMMENTS:
REPAIR WORK INSPECTED AND APPROVED
have inspected the repair of the above right-of-way and find it to be completely satisfactory.
('City Inspector)
(Date Released)