CITY OF INDEPENDENCE, KANSAS
PERMIT TO WORK IN R.O.W. OR EASEMENT
T
ype of work to be performed: ________________________________________________________
__________________________________________________________________________________
L
ocation of work to be performed: _____________________________________________________
__________________________________________________________________________________
O
wner(s): ________________________________________________________Note: Owner(s) are
Address: ________________________________________________________ responsible for any
________________________________________________________ damages occurring as
a result of work
performed for (1) yr.
Contractor: ______________________________________ Contr. City Lic. No.___________________
(Must have a City License to work within City)
Dates work to begin: ______________________________ Est. Completion Date: ___________________
Estimated Size of Roadway Cut: (Length) ________ (Width) _________ (Depth) ___________
Existing Roadway Surface to be Cut: Asph. _______ Conc. ______ Gravel _______ Other _______
If other, Explain: ______________________________________________________________________
A
re Stakes Required for Line and Grade: ____ Yes ____ No
Street Will Need to be Closed: ____ Yes ____ No
Special Traffic Control Required: ____ Yes ____ No
Temp. Pavement Repair Required ____ Yes ____ No
Kansas One Call notified for any digging: ____ Yes ____ No
Kansas state law requires the Kansas One-Call be notified before any digging work is performed. 1-800-Dig-Safe (1-800-344-7233)
T
amped by: _________________________________ How Tamped: __________________________
T
ype of Material Used for Backfill: _______________________________________________________
D
ate of Permanent Repair to be Made: _____________________________________________________
Remarks: ____________________________________________________________________________
A
pplicant Signature: ___________________________________________________________________
Permit invalid without signature
C
ity Signature: ________________________________________________________________________
NOT VALID AFTER 30 DAYS
FOR INSPECTION CALL: 620.332.2541
FOR OFFICIAL USE ONLY
Nonconformance Complaint(s): _____________________________________________________
Fine(s): _________________________ Date: __________________________________________
Repairs made and billed: ___________________________________________________________
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