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HomeMy WebLinkAboutRight-way-permit-appRIGHT-OF-WAY PERMIT % PERMIT NUMBER: TODAY'S DATE: ESTIMATED DATE OF WORK: (� APPLICANT (Person doing the work) COMPANY: ADDRESS: PHONE: EMAIL PERMIT TO: I� CUSTOMER: ADDRESS:- PHONE:r� ADDRESS OF PROJECT: DESCRIPTION OF WORK (check all that apply) _ ROAD BORE DRIVEWAY REPLACEMENT CONSTRUCTION ENTRANCE LANE CLOSURE STREET CUT ROAD CLOSURE OTHER DESCRIPTION: J TYPE OF SURFACE CUT (if applicable): *NOTE. OPEN CUTS IN PAVEMENT REQUIRE BOARD OF PUBLIC WORKS (BPW) APPROVAL USE OF HEAVY EQUIPMENT YES F—, NO 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: EXPIRATION DATE: (� , J 0 As applicant for this Right -of -Way Permit, l understand and agree to all of the specifications and conditions listed on the attached sheet (A Ii, is Signature)',1i r- 0 (Print Nam 1101 PERMIT GRANTED BY: DATE ISSUED: (City Official) COMMENTS: 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)