City of Jeffersontown – Residential Driveway Connection Application 20150301 Page 1 of 1
City of Jeffersontown
Department of Permitting and Enforcement
10416 Watterson Trail
Jeffersontown, KY 40299
Phone: (502) 267-8333 Fax: (502) 267-
jeffersontownky.gov
FOR OFFICE
USE ONLY
Date:
________________
Permit Number:
________________
Residential Driveway / Connection Application
APPLICANT INFORMATION
(Please Print)
CONTRACTOR:___________________________________________________________________________________
Mailing Address:____________________________________________________________________________________
City:____________________________________ State:_____________________________ Zip:____________________
Phone:___________________________________________ Email:___________________________________________
Physical Address of Site (If different):___________________________________________________________________
PLEASE ATTACH MAP-PLOT PLAN / DRAWING SHOWING DRIVEWAY / APRON DIMENSIONS,
LOCATION AND CROSS SECTION OF DRAINAGE FEATURES
PROPERTY OWNER (If different than above.):__________________________________________________________
Mailing Address:____________________________________________________________________________________
City:____________________________________ State:_____________________________ Zip:____________________
Phone:___________________________________________ Email:___________________________________________
Physical Address of Site (If different):___________________________________________________________________
CERTIFICATION
I certify that I am familiar with the information contained in this application and that to the best of my knowledge and
belief such information is true, complete and accurate. I will not begin work on the driveway / connection until I receive
my permit. I understand that failure to do so could result in a citation and a one hundred dollar ($100.00) per day fine. I
understand all conditions of the permit. When I begin work on the driveway / connection I am accepting all conditions
listed in my permit.
Signature: ___________________________________________
Printed Name:________________________________________
Date:_________________________________
