HomeMy WebLinkAbout19080174 Right Of Way PermitAPIP (D ~_
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DAY'S DATE:
APPLICANT (Person doing the work)
COMPANY:
ADDRESS:
SJ
PHONE:
Sa '%
CUSTOMER:
y.
ADDRESS:
PHONE:
/ y;
RIGHT-OF-WAY PERMIT
PERMIT NUMBER: Z
ESTIMATED DATE OF WORK: 10 t Z✓�
EMAIL PERMIT TO: J, ,rf�J �`(Imor"It1V,(k-,VJAGCofil,
llf&
ADDRESS OF PROJECT: I J `t ✓'y (i(z
DESCRIPTION OF WORK (check all that apply)
ROAD BORE DRIVEWAY REPLACEMENT _
CONSTRUCTION ENTRANCE LANE CLOSURE
STREET CUT ROAD CLOSURE
OTHER _
DESCRIPTION:
TYPE OF SURFACE CUT (if applicable):
*NOTE: OPEN CUTS /N PAVEMENT REQUIRE BOARD OF PUBLIC WORKS (BPW) APPROVAL*
USE OF HEAVY EQUIPMENT YES )C 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: �ji/T II
As applicant for this Right -of -Way Permit I understand and agree to all of the specifications and
conditions listed on the attached sheet.
Tom Lazzara
(Applicant's Signature)
PERMIT GRANTED BY:
(Print Name)
DATE ISSUED: ?,//
(City OfYcial)
COMMENTS:
w.o /Z
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)
II