Transcription of APPLICATION FOR ROADWAY/SIDEWALK PERMIT(S)
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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 widths and proposed Work Zone)___ 0402 CONSTRUCT NEW SIDEWALK___ 0704 CANOPY FOR MISCELLANEOUS___ 0403 REPLACE SIDEWALK___ 0705 CANOPY FOR SIDEWALK CAF SIDEWALK CONSTRUCTION PERMITS___ 0702 CANOPY FOR RESTAURANT___ 0401 REPAIR SIDEWALK___ 0703 CANOPY FOR RESIDENCE___ 0127 CONDUIT CONSTRUCT
9. DOB#: Provide any applicable Department of Buildings permit numbers. 10. House No.: Provide the house number of the building where the proposed work will occur. 11. On Street: Provide the name of the street where the proposed work will occur. 11a.
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