Revised April 2016
Road Cut or Closure Permit
Street Department
310 Navajo Trail Burns Harbor, IN 46304
P 219-787-9187 F 219-787-0015
@burnsharbor-in.gov www.burnsharbor-in.gov
TO BE FILED A MINIMUM OF FORTY-EIGHT (48) HOURS BEFORE WORK IS TO COMMENCE
Applicant Name
Application Date
Contractor License Number
I hereby make application for a permit to close or cut a __ street, __ alley, or __ public grounds at the following
location:
The excavation will be _____ feet long in right-of-way and _____ feet long in road surface by _____ feet wide.
Approximate date of commencement of work
Approximate working days required to complete work
Reason for cut or closure:
Note: A detailed drawing or map showing an alternate route for traffic must be submitted at the time of application.
The alternate route must be such that emergency vehicles may pass through. A valid Contractor's License must
also be in place before this permit may be released.
I understand that an application fee of $200 .00 is to be submitted to the Street & Building Clerk to cover the cost
of inspection and processing of application for a street or alley cut. The application fee for a sidewalk cut shall
be $50.00. A fee of $50.00 shall be charged for a road closure in which no cut is made.
I further understand that it is my responsibility to contact Indiana Underground Plant Protection Systems, Inc. at
1-800-382-5544 at least forty-eight (48) hours in advance (excluding weekends & holidays), but no more than
twenty (20) calendar days before digging or drilling. I also agree that I will not dig or drill until the site has been
inspected and the underground utilities have been properly marked.
I agree to erect and maintain all necessary barricades, detour signs, and warning lights required to safely direct
traffic over or around the part of the road where the above described work is to be done.
lmccormick
Revised April 2016
Road Cut or Closure Permit
Page 2
I agree that all surfaces, piping, and/or structures removed, disturbed, or otherwise altered by the work shall at
the applicant's expense, be returned to its original condition, or to a condition meeting the existing requirements
of the Town of Burns Harbor, whichever is more stringent.
I agree to assume all responsibility for any injury or damage to persons or property resulting directly or indirectly
from the work to be performed.
I agree that said work will not interfere with any existing structure in, along, or across said street or public grounds,
unless permission has been granted from the owner of said structure.
I agree to stop work at any time upon request of the Burns Harbor Street Commissioner or his authorized agent.
I agree no opening in any street, alley or public grounds within the Town shall remain in need of repair for a
period of more than (10) consecutive days. If necessary, the street commissioner may grant an extension.
I further agree to accept responsibility for any repairs to said excavation for period of one (1) year.
Street Commissioner Signature
Authorized Agent Signature
Application Approval Date
Date Permit is to be released
(1 year from the time permit is granted)
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