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Right of Way Permit Application
RIGHT-OF-WAY PERMIT DAY'S DAi'E: �;��'�/ �¢ � O APPLICANT [Person doing the workj COMPANY: ��y(1� f,IlLir ADDRESS: � �� �j f�,' /� � PHOiVE: IcusroM�R: PHONE AUDRE55 QF PROJftT: Sr Q� C�.�,��, F.,�, � Q;� e f,�� �,��� �� �,� �.� �;� � DESCRIPTION OF WORK (checCc all that applyy ROAD BQRE � DRlVEWAY REPLACEMENi ❑ CONSTRUCTIQN ENTRA�ICE ❑ LANE C�05URE � STREEi Cl1T �] ROAD CLOSl1RE � ,OiHER � 'DESCR[PTION: /�'/0 G�r�R.� /�Ei 7���. ,QOu� . 1���cx -� ��'� �� �.�,�;�.v� fc� ;,v,��q,� ��'�1��� E QF SURFACE CUT (if appiicahfe): *NOTE: QPEN CUT51N FAVEMENT RFQUlRF BOARD OF FU8L1C WQIiKS (BPWJ APPRQVAL * US� �F HEAVY EQUIPMENT YES X �VO � DRAWING ATTACHED YES NO � *NOTE; qN REVERSE SIDE QF 71115 RERMIT, PliQVI�E NAMES Af�D CQWiACTS OF ALL SUB-C�NTi2ACTDRS INVQLVEQ SUREi1f BOND. Please see Item #1 of the Right-af-Way Car�ditians. BONRING COMPANY: f ��xLjLT`� ,/,'?c, �'L�,G'� f�'/?ET `-� BONDING NUMBER: ���� � �ag�, . _. .__.... ,,..,._,-- EXPERATIOIV DATE: � „t/ wa�./ PERMIT NUM6ER: � ESTIMA��D pA7E OF WORK: � / ��,,i-L� �.n,7J � 1 �--�� (_'�ci 5�'�o/i': ��J/ ���d2- c:�L� j/�"S��'SS�� EMAlLPERMiTTO:�.4�N1I.L�:'�C�1'D�Ji�l.f:[r>-ID1�s�'t�l� .���� _ �-�� r� � �'� i�� � s�<iG�1l�{�'aO�J Ci1L° �?(.,� L� �QQ�U !� _.. �� � ;j._.��. �i� •- 3�v" ��.�� , ,. , .... N �E��-� � 4 As applic f• i Right-af-Wpy Permit, 1 understand and agree to a!! af Phe specifications and � f conditions listed an i'he a�-tached sheet. � ��a��°Y �, ��t.�. �t's Signature) (Print Narne} IT GiiANTER �Y: (City Qffitial) DATE I55UEp: COMMENTS: RE�AIR W�RK INSP�CTED AND ARRROVED f have inspected the repair of the abave right-of-way and find it ta be completeiy satisfactory. (City Inspector) (Date Released)