HomeMy WebLinkAboutROW PermitRIGHT-OF-WAY PERMIT
PERMIT NUMBER:
TODAY'S DATE: Ci -��j—�� ESTIMATED DATE OF WORK:
APPLICANT (Person doing the work)
COMPANY:515
ADDRESS: E, 75aL'4� Est
PHONE: 3n-4�&5-1oS14 EMAIL PERMITTO: _1Lllm��(VitJnCSlIs cti.� r�rr cAm
CUSTOMER: �n �pCt s
ADDRESS:
PHONE:
ADDRESS OF PROJECT: 4648 Sr l\
DESCRIPTION OF WORK (check all that apply)
ROAD BORE DRIVEWAY REPLACEMENT _
CONSTRUCTION ENTRANCE _ LANE CLOSURE
STREET CUT _ ROAD CLOSURE
OTHER,!
DESCRIPTION: hgQVu ecLw-omcy cin\jim,
TYPE OF SURFACE CUT (if applicable):
*NOTE. OPEN CUTS IN PAVEMENT REQUIRE BOARD OF PUBLIC WORKS (BPW) APPROVAL*
USE OF HEAVY EQUIPMENT YES NO -
DRAWING ATTACHED YES i NO
*NOTE: ON REVERSE SIDE OF THIS PERMIT, PROVIDE NAMES AND CONTACTS OF ALL SUB -CONTRACTORS INVOLVED
IbUKt:I r UUND. Please see Item #1 of the Right -of -Way Conditions.
BONDING COMPANY:
BONDING NUMBER:
EXPIRATION DATE:
As applicant for this Right -of -Way Permit, / understand and agree to all of the specifications and
conditions listed on the attaFhed sheet.
licant's Signature (Print Name) �-
PERMIT GRANTED BY: 0 <n? DATE ISSUED:
COMMENTS:
(City Offid-iaI)
iM
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)
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