HomeMy WebLinkAboutRight of Way PermitRIGHT-OF-WAY PERMIT
PERMIT NUMBER:
TODAY'S DATE: I - 01' k
APPLICANT (Person doing the work)
COMPANY:
Y)%UQ, VWL
ADDRESS:
PHONE:
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CUSTOMER:
GeOC- 'F
ADDRESS:
-Zc�-vl S
ESTIMATED DATE OF WORK: DC-+ r Q (�
EMAIL PERMIT TO: RM
O`�k l e- , like,
PHONE: -730 - 65d9�
ADDRESS OF PROJECT: O�Q�—I J a-V\V\0oL
DESCRIPTION OF WORK (check all that apply)
ROAD BORE ❑ DRIVEWAY REPLACEMENT
CONSTRUCTION ENTRANCE LANE CLOSURE I
STREET CUT ROAD CLOSURE 7-7 11
OTHER El
DESCRIPTION:
TYPE OF SURFACE CUT (if applicable):
*NOTE: OPEN CUTS IN PAVEMENT REQUIRE BOARD OF PUBLIC WORKS (BPW) APPROVAL*
USE OF HEAVY EQUIPMENT YES NO I I
DRAWING ATTACHED YES NO
(*NOTE: ON REVERSE SIDE OF THIS PERMIT, PROVIDE NAMES AND CONTACTS OF ALL SUB -CONTRACTORS INVOLVED I
SURETY BOND. Please see Item #1 of the Right -of -Way Conditions.
BONDING COMPANY:
BONDING NUMBER:
EXPIRATION DATE:
As applicant for this Right -of -Way Permit, I understand and agree to all of the specifications and
conditions listed on the attached sheet.
(Applicant's Signature) (Print Name)
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.
(Date Released)
(City Inspector)