HomeMy WebLinkAboutrightofway 4RIGHT-OF-WAY PERMIT
PERMIT NUI ISM. #Q
A P P P (D � 'P: D"
TODAY'S DATE: ' ' ESTIMATED DATE OF WORK. - �
APPLICANT (Person doing the works r
COMPANY. ,� � � = r .
ADDRESS:'
PHONE: j S - EMAIL PERMIT TO
CUSTOMER-
ADDRESS:, [
PHONE:
ADDRESS Of PROJECT: L % d.,`" f
0ESCRIPT10N OF WORK jcheck a]I that apply) _
ROAD BORE DRIVEWAY REPLACEMENT
CONSTRUCTION ENTRANCE LANE CLOSURE
STREET CUT ROAJT CLOSURE
CPTH E R _
DESCRIPTION-
TYPE Or SURFACE CUT (if applicable)-
*NOTE: OPEN CUTS IN PA VEMEN T REQUIRE BOA RD OF PUBLIC WORKS (DPW) APPROV Ai
USE OF HEAVY EQUIPMENT ''ES }x ND _
DRAWING ATTACHED YES NO
1 `NOTE: 01Y REVERSE 51 GE OF THIS PERMIT, PROVIDE KAMES AND CONTACTS OF ALL 5UI3--CONTRACTORS INVOLVED
SURELY BOND. Please see Item 41 of *he Right -Way C nditions-
BONDING COMPANY:
BONDING NUMBER: .�
EXPIRATION DATE=
f
4s ap rrt for as Right -of -1 oy Permit, f understand and agree to ate of the specr-fxacioels and
conditions fisted on thea pached sheet
(App11Can#'s Signa afire) (Print Name)
PERMIT GRANTED BY:
(City Offirial)
COM M E NTS:
DTE 15SUED: //l0,
L --k L2,� Z-7 J 4 7
REPAIR WORK INSPECTED AND APPROVED
I have inspected the repair pf the above right-of-way and find °t to be completely satisfactory.
(City Inspector)
{Date Reieased]