HomeMy WebLinkAboutjacksonrow 4APPROVED
RI(aHT-OF-WAY PERMIT
PERNAlT NuMBI=R: Garme` Er.,. r rang Dept.
! � , I f ST[MA7FD DATE DF WORK
TODAY'S OAVI
APPLICANT (person doing #fie work)
Cy _7177-77, 61151
COMPANY: I
ADDRESS' -'v
EMAIL P1=RMIT TO:
CUSTOMER:
ADDRESS: -
PHON .
ADDRESS OF PROACT:
Dall that apply) DRIVEWAY REPLACEMENT
SCTiiPT1ON Of QfiK {check
ROAD BORE LANIli CLOSURE _
CONSTRUCT ION ENT RANGE ROAD CLOSURE
STREET CUT
OT KE R*x
DESCRIPTION;
TYRE OF SURFACE CUT (if appilCalnlel'
*NOTE: OPEN CUTS IN PAVEMEN714EQUME BOARD OF
UBZfC WORKS8p1N APPROVAL
NO
USE OF HEAVY EQU1pmEt4T YES NO
DRAWING A7TA,CHED YES
`NOTE -r REVIK SIDE Of TSIS PERMIT, PROVIDE DAMES AND CONTACTS OF ALL Skill -CONTRACTORS INVOLVED
:
SURELY BOhtD. Please see Item #1 of the Right I'llQf Way Conditions. Y
BONDING COMIPANY:
BONDING NUhhBER-
E)(PIRAT1ON DATt_
AS orlrcarit far this 14rgf�t-of-Way Per►rfi#, inderstarrd orrda�ree to a+� of the seCffCutions arrd
• . conditions listed on OF attached 5 C-
Print Name)
(ApPrir,ant's Signature)
DATE ISSUED_ !
PERMiIT GRANTED BY' (City OfFi€ialj
COMMENTS-.
REPAIR WQFM INSPECTED AND APPROVED
I have inspected the repair of the above righ#-of -waY and Lind it to be completely 5atisfecCor'1-