HomeMy WebLinkAboutRight of Way Permit 2Y'S DATE: IO - 01` kc�
APPLICANT (Person doing the work)
COMPANY:
ADDRESS:
PHONE:
CUSTOMER
ADDRESS:
RIGHT-OF-WAY PERMIT
PERMIT NUMBER:
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ESTIMATED DATE OF WORK: nc+ 1� Q (c�-
EMAIL PERMIT TO:
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PHONE: 311— -730 - (:::,,509,
ADDRESS OF PROJECT:
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DESCRIPTION OF WORK (check all that apply)
ROAD BORE
DRIVEWAY REPLACEMENT
171
CONSTRUCTION ENTRANCE
LANE CLOSURE
STREET CUT
ROAD CLOSURE
OTHER
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DESCRIPTION:
OF SURFACE CUT (if applicable):
`NOTE. OPEN CUTS IN PAVEMENT REQUIRE BOARD OF PUBLIC WORKS (BPW) APPROVAL;
USE OF HEAVY EQUIPMENT YES NO H
DRAWING ATTACHED YES NO
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I'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: e-
BONDING NUMBER:
EXPIRATION DATE:
As applicant for this Right -of -Way Permit, l understand and agree to all of the specifications and
conditions listed on the attached sheet. I
Applicant's Signature) (Print Name)
PERMIT GRANTED BY:
(City Official)
COMMENTS:
DATE ISSUED:
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)