HomeMy WebLinkAboutCompleted Right of Way PermitRIGHT-OF-WAY PERMIT
PERMIT NUMBER:
TODAY'S DATE: �D �� ! ESTIMATED DATE- OF WORK: � � 'J��� 2, of I
APPLICANT (Person doing the work)
COMPANY- C— U S�OVIA�.CO'o—
ADDRESS: 2 OL{�n�� �p G,t WA
PHONE: EMAIL PERMIT TO: ` dl �: (� C LtS fO ON okt
CUSTOMER:
ADDRESS: tar / i/
PHONE: 3 ) ■ bq!0 14^c���14 3r'� dos-D�s� h o,,,
AI DDRESS OF PROJECT: �j J('t 1�) V'`Z �P� ✓\
. DESCRIPTION OF WORK (check all that apply)
;ROAD BORE ❑ DRIVEWAY REPLACEMENT ❑
CONSTRUCTION ENTRANCE ❑ LANE CLOSURE ❑
STREET CUT ❑ ROAD CLOSURE ❑
OTHER 0� /� j
DESCRIPTION: y LC`��a.� GI C am S �1 `t k r b P 7 f c wG
TYPE OF SURFACE CUT (if applicable): qu , P� QLn, an
ll *NOTE: OPEN CUTS IN PAVEMENT REQUIRE BOARD OF PUBLIC WORKS (BPW) APPROVAL*
jUSE OF HEAVY EQUIPMENT YES 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. I
BONDING COMPANY: �� � l %AC.� 1 ../-�6kt/kV-� �i
BONDING NUMBER: Q
EXPIRATION DATE: 'Q
As applicant for this Right -of -Way Permit, I understand and agree to all of the specifications and
6\ . 1 conditions listed on the attached s�t.
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.
(City Inspector) (Date Released)