HomeMy WebLinkAbout07080216 Right-of-Way PermitAPPROVED
RIGHT-OF-WAY/STREET CUT PERMIT NO. U ?a 70 7 -.3
Note: Open cuts in pavement require Board ojPublic Workr (BPI9 Approval.
LOCATION OF CUT/WORK: /S V1:3 OL D M 1 L -L- C )R L Ac
TYPE OF SURFACE TO BE C)T:
PURPOSE OF STREET-9q/WORK: _ Gi c? r w ?S f R + it 9?n t nu?&" ?te
DATE OF PERMIT: S- `/- 2,067 ESTIMATED DATE OF WORK: A<?g r 2cXAPPLICANT'S NAMEf60" ! Ffn rJ ' f 1 d' y' kt IS PHONE:
ADDRESS: 3-k1/ C?urks C°r?r/ 14,4 3f7 7/x_3 ys
WHO IS APPLICANT DOING WORK FOR: name ai11 ,1( rta S?k n4
ADDRESS: I SS! 3 f?jd M +, C ) r,j ? PHONE: SeF
/ n? 1T
NOTE: UNDER SEPARATE COVER, PROVIDE NAMES AND CONTACTS OF ALL SUB-
CONTRACTORS TO BE INVOL I N-SITE WORK ON THIS PROJECT.
PERMIT ISSUED BY: (signature)
SURETY BOND AMOUNT $
BONDING COMPANY:
OR
CERTIFIED CHECK AMOUNT:
BANK:
CHECK NO.
As applicant for this right-of-way/street cut permit, I understand and agree to all the specifications and
conditions listed on the reverse side of the permit.
(Applicant's Signature)
I have ins ted the repair of i
right-of-way/street cut and find it to be completely satisfactory.
(City Inspector)
(Date)
If applicable:
Check returned: By: