HomeMy WebLinkAbout19110072 ROW PermitRIGHT-OF-WAY PERMIT
PERMIT NUMBER:
TODAY'S DATE: i���' �� ESTIMATED DATE OF WORK: I Z`� v l�
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APPLICANT (Person doing the work) -6„� v� �--���J
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COMPANY: Y I !�"�-�'�� �-tti(', t� � �, ,
ADDRESS:
PHONE:
CUSTOMER:
ADDRESS:
PHONE:
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ADDRESS OF PROJECT: ���� �� ��•;)uc., I�l�'� I C�iv�'-z, (��'v
DESCRIPTION OF WORK (check all that apply)
ROAD BORE �; DRIVEWAY REPLACEMENT �
CONSTRUCTION ENTRANCE � LANE CLOSURE �
STREET CUT I� ROAD CLOSURE I
OTHER �
DESCRIPTION: �(�,-� �V� � "N��I' `^-i � �'�
TYPE OF SURFACE CUT (if applicable):
*NOTE: OPEN CUTS IN PAVEMENT REQUIRE BOARD OF PUBLIC WORKS (BPWJ APPROVAL*
USE OF HEAVY EQUIPMENT YES � � NO � J
'DRAWING ATTACHED YES �_j NO 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 Rieht-of-Wav Conditions.
BONDING COMPANY:
BONDING NUMBER:
EXPIRATION DATE:
As applic nt f
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(Appl'c nt's Signatur
PER GRANTED BY:
COM M ENTS:
this Right-of-Way Permit, 1 understand and agree to all of the specifications and
conditions listed on the attached she�t. ^ A �
�i �� `� ���' �-�-1 �
� (Print Name)
DATE ISSUED:
(City Official}
REPAIR WORK INSPECTED AND APPROVED
I have inspected the repair of the above right-of-way and find it to be completely satisfactory.
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(City Inspector) (Date Released)
'��% "Cj� �� �' � 1 EMAIL PERMIT TO: