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)