HomeMy WebLinkAboutRightofWayRIGHT-OF-WAY PERMIT
PERMIT NUMBER:
DAY'S DATE: ;;� ��.���� ,� �:� ESTIMATED DATE OF WORK: � � � ��� .�� ���`� ' ����� ���
PLICANT (Person doing the work) ",..y., , V�. �� ��,� � � � � ��_ �
COMPANY:
ADDRESS:
PHONE: �, �a� � �
CUSTOMER:
ADDRE55:
PHONE:
�
��
��� �;�
_� �
� �n u.�� �� .
ADDRESS OF PROJECT: d� ��d� �� � z"�
DESCRIPTION OF WORK (check all that apply)
ROAD BORE ^
CONSTRUCTION ENTRANCE
STREET CUT
�. =.a
��
. �.
OTHER
DESCRIPTION:
TYPE OF SURFACE CUT (if applicable):
a: �.� ��.
�n
�t �'��� �'���1 d � �F'
DRIVEWAY REPLACEMENT
LANE CLOSURE
ROAD CLOSURE
�
i
L _.
�� � �
� y���� �
*NOTE: OPEN CUTS /N PAVEMENT REQUIRE BOARD OF PUBLIC WORKS (BPWJ APPROVAL*
USE 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.
a; �
BONDING COMPANY: ' .� dd�' „' r� � "`�°:��-�r '�`��;r'�;�
BONDING NUMBER:
EXPIRATION DATE:
;� � �� � `� �
�
� � _ �., �
�i.�s,
�A
As applicant for this Right-of-Way Permit, 1 understand and agree to all of the specifications and
�, _ conditions listed on.t,he attache,.d sheet..
� � � �:
, �
�� �� � Q� ��`��,�� �° - � � ,
icant'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.
(City Inspector)
(Date Released)
,
��� '��:.
� �:�� �� C ��y��
, �` �