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APPLICATION FOR ROADWAY/SIDEWALK PERMIT(S)

Rev. 9/15/10 8. Type of Pavement: a. Roadway_____ b. Sidewalk_____ 10. House No.:_____Permit :22. Date:_____/_____/_____(Authorized Representative of Applicant)Date(Please Print) / / 21. Signed by:_____ No permit shall be issued unless all applicable insurance and permit bonds are on file. 19. Submitted by:_____20. Tel #:(_____)_____-_____(For Official Use Only) SECTION F: Acknowledgements and Agreements by Authorized Representative of the ApplicantApproved for the Commissioner by: The permit to be granted is subject to the following conditions: The applicant agrees to comply with all laws and rules of the Department and any other applicable laws and rules. Additional Fees: Inspection:_____ Tunneling:_____ Other (Specify):_____OCMC Approval by: / / Special Stipulations: permit StipulationsPermit Number SECTION E: permit Stipulations (For Official Use Only)___ 0405 CONSTRUCT NEW SIDEWALK - BUILDERS PAVEMENT___ Other Type of permit _____ SECTION D: Work Zone Sketch (Include On Street, both Cross Streets, North Arrow, Sidewalk/Roadway w)

APPLICATION FOR ROADWAY/SIDEWALK PERMIT(S) SECTION A: Applicant Information * See reverse for instructions on how to complete this form. 19. For the work location listed above: Check YES if at least ONE of the following is applicable. Check NO if NONE of the following is applicable:

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Transcription of APPLICATION FOR ROADWAY/SIDEWALK PERMIT(S)

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