Right-of-Way Activity Permit Application
Department of Public Works / Engineering
Permit No.: ___________________ Permit Issued: ____________
Expiration Date: ____________
Property Address: ___________________ Permit Fee: ____________
Special Conditions: __________________________________________________________________
Action: Approval Denial
_______________________________________ _________________________ ____________
Signature of Reviewer Title Date
Permit Information
(Please Print)
List Activity/Obstruction to be placed in Right-of-Way:______________________________________
Include a written plan of action from applicant shall include the following:
Barricades, Lights, Cones, Tape (safety of pedestrians and vehicle traffic)
Daily cleaning of area
Containment of debris
Defined pick-up and removal schedule
Site Plan
Compliance with appropriate municipal code requirements
Type of Building Commercial / Industrial Residential
Location of Activity/Obstruction: On Property On Street On Sidewalk
(No dumpsters shall be placed upon a sidewalk)
Time Period for Activity/Obstruction: Start Date: _______________________
Finish Date: _______________________
Container Vendor: ______________________________________________________
Property Owner: ______________________________________________________
Property Owner Address: ______________________________________________________
Contractor / Applicant: ______________________________________________________
Contractor / Applicant Address: ______________________________________________________
Contractor / Applicant Phone No. _______________________Fax No.________________________
Contractor / Applicant E-mail__________________________________________________________
I hereby certify that this permit is pursuant to work authorized by the owner of record and I am authorized to make this application as the authorized agent and
we agree to conform to all applicable laws of jurisdiction. Failure to comply with the provision set forth in the municipal code requirements regarding the
placement and care of right-of-way obstruction will cause this permit to be revoked and/or the filing of criminal charges necessary to provide compliance.
Signature of Applicant: ___________________________________________ Date: _____________
Cc: Public Works / Streets; Salina Fire Department; Salina Police Department; Salina Downtown; File
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