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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