HomeMy WebLinkAboutRight-of-Way Permit App 6-19-19RIGHT-OF-WAY PERMIT
PERMIT NUMBER:
TODAY'S DATE: (�f — /?— rq ESTIMATED DATE OF WORK:
APPLICANT (Person doing the work) _j 0&
COMPANY:
ADDRESS:
PHONE:
CUSTOMER:
ADDRESS:
C )538- 7Cv y EMAIL PERMIT TO:
PHONE: �3tz Tl (.
.0
ADDRESS OF PROJECT: 1 ZCe 50 &%TF P_
DESCRIPTION OF WORK (check all that apply)
ROAD BORE ❑ DRIVEWAY REPLACEMENT ❑
CONSTRUCTION ENTRANCE E LANE CLOSURE 17
STREET CUT ROAD CLOSURE
OTHER
DESCRIPTION: 7- 1V 7-0 nJ ►�/�
TYPE OF SURFACE CUT (if applicable): Aj
r
*NOTE: OPEN CUTS IN PAVEMENT REQUIRE BOARD OF PUBLIC WORKS (BPW) APPROVAL*
USE OF HEAVY EQUIPMENT YES � NO 5j;
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: WF -,5 tW 5 V RZT--[ Lnco_PAL {~
BONDING NUMBER: Gnueqax[031{o jz o/
EXPIRATION DATE: Ze L J_9 Z !d -- ZCo --/q
As applicant for this Right -of -Way Permit I understand and agree to al/ of the specifications and
Conditions list don the Vttshed sheet.
(Applicant's Signajure) (Print Name)
Lew_ M111031-YA
(City Official)
DATE ISSUED:
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)
I