Fillable COOK COUNTY HIGHWAY DEPARTMENT PERMIT APPLICATION (Cook County Government - Bureau of Technology)

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COOK COUNTY HIGHWAY DEPARTMENT PERMIT APPLICATION (Cook County Government - Bureau of Technology)

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BROWSE COOK COUNTY GOVERNMENT - BUREAU OF TECHNOLOGY (IL) FORMS

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Office Use Only:
Permit No.:
Opened By:
COOK COUNTY HIGHWAY DEPARTMENT PERMIT APPLICATION
Cook County Department of Transportation and Highways Permits Office
312.603.1670
George W. Dunne Cook County Office Building
312.603.9943
hwy.permits@cookcountyil.gov
69 W. Washington, 24th Floor, Chicago, Illinois 60602
Revised 2020/11
Page 1 of 2
Print clearly or Type all information requested. Incomplete applications will NOT be accepted.
Application Fee: $
Fee Receipt #:
24hr Emergency Contact Name: Phone Number:
Cook County Permits requires a 24hr emergency contact name and phone number for 24hr response if an off-hour hazard is called into Cook County
and is the Hazard is tied to this permit work. This can be an Owner, Engineer/Architect or Contractor number.
Owner:
Name:
(Legal Name of Company/Owner) (Contact Name/Title)
Mailing:
Address City State Zip
Phone: Email
Engineer/Architect: (Primary Firm Assigned to prepare Civil Engineering Plans)
Name:
(Legal Name of Company/Owner) (Contact Name/Title)
Mailing:
Address City State Zip
Phone: Email
General Contractor: (Contractor assigned to oversee all the work requested in this permit)
Name:
(Legal Name of Company/Owner) (Contact Name/Title)
Mailing:
Address City State Zip
Phone: Email
Owner of Existing Water Main: (Required if proposing water connection)
Name:
(Legal Name of Company/Owner) (Contact Name/Title)
Mailing:
Address City State Zip
Phone: Email
Owner of Existing Sanitary Sewer: (Required if proposing sanitary connection)
Name:
(Legal Name of Company/Owner) (Contact Name/Title)
Mailing:
Address City State Zip
Phone: Email
Office Use Only:
Permit No.:
Opened By:
COOK COUNTY HIGHWAY DEPARTMENT PERMIT APPLICATION
Cook County Department of Transportation and Highways Permits Office
312.603.1670
George W. Dunne Cook County Office Building
312.603.9943
hwy.permits@cookcountyil.gov
69 W. Washington, 24th Floor, Chicago, Illinois 60602
Revised 2020/11
Page 2 of 2
Project Location: (Complete all information. Print or type clearly.)
Property Address:
Site City or Cities:
County
Hwy(s)/ Hwy Section #(s):
See Cook County jurisdiction map for County Route Name(s) and Hwy Section #(s). Note, Cook County Jurisdiction Routes are solid red on the jurisdiction Map. Click Here For Map.
Locations to nearest cross street:
Description of Work:
-Within Cook County ROW
-Attach sheet if need room
Proposed Work: (Check all items that apply within Cook County ROW only)
Entrance/Access
Entrance Commercial New,Modify,Rem and/or Repl
Entrance Residential New,Modify,Rem and/or Repl
Entrance Street New,Modify,Rem and/or Repl
Entrance Temp Construction, Temp Access
Curb and Gutter New,Modify, Rem and/or Repl
Storm Sewer/Pipe Culvert and Appurtenances New,
Modify, Rem and/or Repl
Utilities
Water Main and Appurtenances New, Modify,
Rem and/or Repl
Water Service New, Modify, Rem and/ or Repl
Sanitary Sewer and Appurtenances New,
Modify, Rem and/or Repl
Sanitary Sewer Force Main and
Appurtenances New, Modify, Rem and/or Repl
Sanitary Service New, Modify, Rem and/or
Repl
Landscaping (Municipal
Only)
Parkway/Median Trees New, Rem
and/or Repl
Parkway/Median Plantings New,
Rem and/or Repl
Landscaping
Grading/Restoration
Roadway Improvements
Roadway Reconstruction
Roadway Widening
Roadway Modification
Paths/Walks
Sidewalk New, Modify, Rem
and/or Repl
Bike Paths New, Modify, Rem
and/or Repl
Multiuse Paths New, Modify,
Rem and/or Repl
ADA Improvements
Pedestrian Curb Ramps
Crosswalks
Pedestrian Signals/Push Buttons
Traffic Control/Signage
Lane Closure
Road Closure
Detour
Signage Construction
Signage Permanent New, Modify, Rem and/or Repl
Pavement Marking New, Modify, Rem and/or Repl
Reflective Pavement Markers New, Modify,
Rem and/or Repl
Utility Companies Only
Power Pole New, Modify, Rem and/or Repl
Cable/Fiber New, Modify, Rem and/or Repl
Cable/Fiber and Conduit New, Modify,
Rem and/or Repl
Gas Main New, Modify, Rem and/or Repl
Gas Service New, Modify, Rem and/or Repl
Tree Trimming
Maintenance Individual
Maintenance Annual
Signals/Lighting
Traffic Signal New, Modify, Rem
and/or Repl
Traffic Signal Interconnection New,
Modify, Rem and/or Repl
Flashing Beacon New, Modify,
Rem and/or Repl
Traffic Signal Loops New, Modify,
Rem and/or Repl
Temporary Traffic Signal New,
Modify, Rem
Street Lighting New, Modify, Rem
and/ or Repl
Miscellaneous
Pavement open-cut
Soil borings
Monitor wells
Pavement Cores
Parade/Festival/Race/Event
Other
1: ___________________________
2: _______________________
3: ___________________________
* Parkway Excavation, Pavement Cut and/or Lane Closure are not permitted under Maintenance and Repair permit.
I declare that I have prepared or examined this Application and it is true and correct to the best of my knowledge and belief. I agree to perform all permitted work according to and with all provisions
of the Ordinances of the COUNTY OF COOK and any/all local, state and federal statutes and/or codes. I realize that the Highway Department is relying on the information that I have provided
in this application in the issuance of the Highway Construction Permit and approval of plans and specifications without variations. The permit issued pursuant to this application shall not be construed
to permit any construction upon or within said right of way or use thereof in violation of any provision of any Ordinance of COOK COUNTY or to excuse the owner or the owner’s successors and
assigns from complying therewith.
NOTICE: THIS APPLICATION FORM IS NOT A PERMIT AND IN NO WAY AUTHORIZES THE APPLICANT OR CONTRACTOR TO CONSTRUCT/PERFORM ANY WORK OR HOLD AN EVENT
WITHIN THE COUNTY’S RIGHTS-OF- WAY WITHOUT THE ISSUANCE OF COUNTY HIGHWAY PERMIT.
Owner Name:
Date:
(Print, do not sign electronically)
Applicant Name: Date:
(Print, do not sign electronically)
20
20
1. CHOOSE HIGHWAY
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COOK COUNTY HIGHWAY DEPARTMENT PERMIT APPLICATION (Cook County Government - Bureau of Technology)

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Completed 13 February 2021

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