No
APPLICATION FOR STREET BREAKING PERMIT
CITY OF ARKADELPHIA, ARKANSAS
In space below, show street name and location of proposed cut. Show width and length of cut and give approximate
depth.
FIRM NAME
AUTHORIZED AGENT'S SIGNATURE
DATE
APPROVED BY
DATE
PERMIT FEE: $25.00
AMOUNT RECEIVED
CHECK NUMBER
CASH
RECEIPT#
RECEIPTED BY
DATE
1.
Cost of repair will be accumulated by Street Department and charged to applicant-
2.
When street is to be closed to traffic, applicant is responsible for coordinating with
Police Dept.
FOR STREET DEPARTMENT USE ONLY
YARDS OF GRAVEL AT PER YARD___________
MAN HOURS LABOR AT PER HOUR___________
YARDS OF PRE-MIX AT PER YARD___________
YARDS OF CONCRETE AT PER YARD__________
TOTAL
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signature
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