City of Jeffersontown – Work With In Public Right-of Way 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:
________________
Work With In Public Right-of-Way Application
General Right-of-Way Encroachment Street Cut (Utility Work)
Other (Specify):________________________________________________________________________________
PART 1: APPLICANT INFORMATION
(Please Print)
CONTRACTOR:___________________________________________________________________________________
Mailing Address:____________________________________________________________________________________
City:__________________________________________ State:_______________________ Zip:____________________
Physical Address of Site (If different):___________________________________________________________________
MAP / DRAWING OF PROPOSED LOCATION REQUIRED
PROPERTY OWNER (If different than above.):_________________________________________________________
Mailing Address:____________________________________________________________________________________
City:__________________________________________ State:_______________________ Zip:____________________
Phone:__________________________________ Email:____________________________________________________
PART 2: ENCROACHMENT ACTIVITY
Please describe what work will be conducted within the public rights-of-way for City of Jeffersontown streets.
The under
signed hereby makes application for an encroachment permit to do the work outlined above and if permit is
issued, agrees to comply with all existing City of Jeffersontown ordinances and to complete said work within thirty (30)
days from the date of issuance and does hereby submit a bond with surety satisfactory to the City of Jeffersontown in the
penal sum of five thousand dollars ($5,000.00).
Applicant Signature: ___________________________________________ Date: _______________________________
