ity of Bedford
Public Works Department
1813 Reliance Pkwy
Bedford, TX 76021
Phone 817-952-2200 Fax 817-952-2240
Annual Registration Fee: $50
Permit Period: Jan 1 to Dec 31
Business Name
Primary Contact & Title
Physical Address
Mailing Address
City Zip
City State Zip
Business Phone Fax
Primary Contact Phone Fax
Primary Contact Email
Location of Tank:
Capacity (g) # of Fixtures
Compartment Accessible Yes No
Submittal of Application and Method of Payment
I have read the completed application and know the same is true and correct and hereby agree that if a permit is issued all
provisions of the City Ordinances and State Laws will be complied with whether herein specified or not. I agree to comply with
all property restrictions. I am the owner of the property or the duly authorized agent.
Submit application and pay by cash, check or credit card in person or by mail. (No cash in mail.)
One time charge on my credit card. Application by fax, mail or email. (credit card payment form attached)
harge my credit card on file. Application by fax, mail or email. (last four digits of account #)
Application and payment by phone. (only with credit card information on file)
Application submittals that require drawings shall be processed and paid for after the plan review process has been
completed and approved by the Building Official. Applicants will be notified when this process is complete. Applicants
may receive a permit(s) in the same form of delivery as the application submittal.
Applicant Name (Print)
Applicant Signature
COB-PW Office Use Only
Office Use Only
Permit Number:
City of Bedford
Public Works Department
1813 Reliance Pkwy
Bedford, TX 76021
Ph: (817) 952-2200 Fax: (817) 952-2240
Email: pw.permits@ci.bedford.tx.us
Credit Card Payment Form
Instructions for Completing the Credit Card Payment Form
Enter all credit card information including the payment amount to be charged to your credit card and remember to sign the
form. The City of Bedford cannot process an incomplete form or process credit card payments without an authorized
The City of Bedford does not accept debit cards or check cards that require use of a personal identification number as a
method of payment.
Address information is required for credit card payment as a means of verification. Failure to complete the address
information may result in the payment not being accepted by your credit card institution.
The City of Bedford requires using this form for credit card payments submitted by mail, facsimile, or email. To protect your
credit card information, use only this form.
Credit Card Information must include the 3 digit security code on the back of the credit card: example:
If the cardholder includes a credit card number on any form or document other than the Credit Card Payment Form or
submits this form electronically via fax or email, the City of Bedford will not be liable in the event that the credit card
number becomes public knowledge.
This PDF file contains form fields allowing you to type in your pertinent information. Once filled out, it can be printed out
and faxed to 817-952-2240, scanned and emailed to
pw.permits@ci.bedford.tx.us or mailed to City of Bedford, Attn:
Public Works Permits Processing, 1813 Reliance Pkwy, Bedford TX 76021. Please note for additional security purposes this
PDF file will not allow a filled out form to be saved, only printed.
Credit Card Information
Credit Card Type: Visa MasterCard
Credit Card Account #:
Expiration Date:
3 Digit Code:
(on back of card)
Name as it Appears on Card
Payment Amount: $
(US Dollars)
Credit Card Billing Address
Street Address 1:
Street Address 2:
Daytime Phone:
Email Address:
Payment Information
Describe Purpose of Payment:
I authorize The City of Bedford to keep this information on file for future use.
I do not authorize The City of Bedford to keep this information on file for future use. Please use for the current transaction
I authorize The City of Bedford to charge my credit card account for payment of permits, inspections, contractor registration or
any associated fees with the City of Bedford and to verify the billing address of my Credit Card with the issuing bank upon my
signature. If The City of Bedford is unable to process my payment, I will be responsible for an alternate payment arrangement
and any penalty fee which results. By signing this authorization, I acknowledge that I have read and agree to all of the above.
All information given is complete and accurate.
Card Holders (signature):