HomeMy WebLinkAboutright of way permitRIGHT-OF-WAY P _RMIT APPH_(,)'V1_'L,z
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PERMIT NUMBER-
TODAY'S DATE: �� �� I` ESTIMATED DATE OF WORK: '110111—
APPLICANT
1101(1 APPLICANT (Person doing the work)
COMPANY:
ADDRESS: D I 11'���il' 0(�� �c�(ilol� 1►�i T1��' J
PHONE: �.�?j?7 EMAIL PERMIT TO: yl b�% ❑Cly j�(yl
CUSTOMER: u l0 6L�•-G� f �1YLc/����'t✓i�u��(li
ADDRESS: %�a�� �n#-F n ��-n'r�t.l IK; l �Z
(PHONE: hl -1• C'1X- 1
ADDRESS OF PROJECT: �XjgG
DESCRIPTION OF WORK (check all that apply
ROAD BORE ❑ DRIVEWAY REPLACEMENT ❑
CONSTRUCTION ENTRANCE ❑ LANE CLOSURE ❑
STREET CUT ❑ ROAD CLOSURE ❑
OTHER Ix
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DESCRIPTION: -� �aO� _ r-5w
TYPE OF SURFACE CUT (if applicable):
*NOTE: OPEN CUTS IN PAVEMENT REQUIRE BOARD OF PUBLIC WORKS (BPW) APPROVAL*
USE OF HEAVY EQUIPMENT YES NO H DRAWING ATTACHED YES NO
*NOTE: ON REVERSE SIDE OF THIS PERMIT, PROVIDE NAMES AND CONTACTS OF ALL SUB -CONTRACTORS INVOLVED
SURETY BOND. Please see Item #1 of the Right -of -Way Conditions.
BONDING COMPANY:
BONDING NUMBER: S`5 OS1
EXPIRATION DATE:
As applicant for this Right -of -Way Permit, I understand and agree to al/ of the specifications and
conditions list d on the att ch sheet. JI
;Applicant's Signature) (Print Name)
PERMIT GRANTED BY: DATE ISSUED: Z
(City Official)
COMMENTS:
Iy9Y G7
REPAIR WORK INSPECTED AND APPROVED
I have inspected the repair of the above right-of-way and find it to be completely satisfactory.
(City Inspector) (Date Released)
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