DATE OF APPLICATION:
STREET START DATE
CROSS STREET END DATE
DESCRIPTION DIG SAFE #
PROPERTY OWNER INFORMATION CONTRACTOR/DUMPSTER COMPANY
Property Owner Name:
Address Owner
City/State/Zip Address
Phone/Cell Phone City/State/Zip
Email Address: 24 Hr. Phone:
Excavator (if different than Contractor)
By signing below I acknowledge I have read, understand & agree to abide by policies listed in the regulations,
procedures and instructions. The Superintendent or his designee has the right to revoke any permit and or
bonding from permit holder if all policies and regulations are not followed
CONTRACTOR/OWNER (PRINT)
CONTRACTOR/OWNER (SIGNATURE)
Blocking Repair Replace New Excavation
Width Length Depth Bluestone Y/N
Current Material Replacement Material
Parking Meter Blocked y/n #Meters Meter #
Size On Street On Sidewalk Other
Parking Meters Blocked Y/N #Meters Meter #
Sidewalk $50.00 Curb Cut $100.00
Block Public Space $50.00 Non Compliance $250.00
Block Park Meter $25 per meter per day Emergency $100.00
FOR OFFICE USE ONLY: Approval
Amt Pd Check # Cash Receipt #
SIDEWALK/DUMPSTER/PARKING/ROAD CLOSURE
PERMIT #
LOCATION OF WORK
SIDEWALK/PUBLIC SPACE/CURB CUT
(check)
DUMPSTER
(check)
FEE SCHEDULE
No
No
No
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome