City of Jeffersontown – Permit for Objects in the Right-of-Way Page 1 of 1
City of Jeffersontown
Department of Public Works
10416 Watterson Trail
Jeffersontown, KY 40299
Phone: (502) 267-8333 Fax: (502) 267-
jeffersontownky.gov
FOR OFFICE
USE ONLY
Date:
________________
Permit Number:
________________
Permit for Objects in the Right-of-Way
Applicant Name: ______________________________________________ ___________________Date:___________________
Applicant's Address: __________________________________________________________________________________
Applicant's Phone Number: ________________________________Email Address: ___________________________________
Location(s) of Installation: _______________________________________________________________________________
Checklist for Required Items to be submitted:
Photographs and detail sheets of items to be installed. Number provided: ________________
Scale drawing for Proposed Installation: _____________________________________________________
Insurance Certificate: ___________________________________________________________________
Maintenance Agreement:_________________________________________________________________
Permit Fees: __________________________________________________________________________
Indemnification Statement (See applicable section of City of Jeffersontown Ordinance.)
Approval of Kentucky Transportation Cabinet or Historical or Overlay District, if applicable.
Bond (If required by the Public Works Director.)
Special Notes:_________________________________________________________________________________
The undersigned hereby makes application for a permit to do the work outlined in this application, and if desired
permit is issued, agrees to comply with all existing Ordinances of City of Jeffersontown and all provisions of the
Regulations of the Department of Public Works regulating the use and placement of objects in the public way.
NOTICE: Any person, persons, corporation, agency, partnership, utility or other instrumentality to whom this permit is granted
WILL TAKE NOTICE that no investigation or examination of the work site surface or subsurface thereof, has been undertaken
by the City of Jeffersontown preparatory to the granting of this permit.
SURFACE AND SUBSURFACE EXAMINATION AND INVESTIGATION OF THE WORK SITE SHOULD BE
UNDERTAKEN BY THE PERMITTEE PRIOR TO THE COMMENCEMENT OF THE WORK COVERED
UNDER THIS PERMIT.
In signing the application for the permit sought hereunder the applicant/owner acknowledges that the above
provisions as to Indemnity of the City of Jeffersontown and as to site inspection have been read and hereby agreed
to.
Applicant Signature:________________________________ Date: _____________Phone:_________________
Owner Signature:___________________________________ Date:_____________Phone:_________________
