Fillable Street Cut Permit 704 Fourth Street / PO (Town of Mills)

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Street Cut Permit 704 Fourth Street / PO (Town of Mills)

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The Street Cut Permit 704 Fourth Street / PO (Town of Mills) form is 1 page long and contains:

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  • 7 check-boxes
  • 26 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town of Mills

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Town of Mills Permit #_________________
704 Fourth Street / PO Box 789
Mills, WY, 82644 Fee $_________________
307-234-6679
Incomplete applications cannot be processed
Street Cut Permit
PROJECT INFORMATION
ADDRESS:
DESCRIBE WORK BEING COMPLETED (WATER, SEWER, GAS, TELEPHONE, ETC.):
TRAFFIC CONTROL REQUIRED : □ YES □ NO
START DATE:
DESCRIBE ANY TRAFFIC CONTROL NEEDED:
TRAFFIC CONTROL DRAWING ATTACHED: □
OWNER INFORMATION
NAME:
ADDRESS:
CITY:
ZIP CODE:
TELEPHONE:
CELL:
CONTRACTOR INFORMATION
NAME:
ADDRESS:
CITY:
STATE:
ZIP CODE:
TELEPHONE:
CELL:
BONDED: □ YES □ NO
INSURED: □ YES □ NO
I HERBY CERTIFY THAT THE OWNER OF RECORD AUTHORIZES THE PROPOSED WORK AND THAT I HAVE BEEN AUTHORIZED BY THE OWNER TO
MAKE THIS APPLICATION AS HIS AUTHORIZED AGENT AND WE AGREE TO CONFORM TO ALL APPLICABLE LAWS OF THE STATE OF WYOMING AND
THE TOWN OF MILLS. ALL INFORMATION SUBMITTED ON THIS APPLICATION IS ACCURATE TO THE BEST OF MY KNOWLEDGE.
APPLICANT SIGNATURE:
APPLICATION DATE:
TOWN OFFICIAL
APPROVAL SIGNATURE:
APPROVAL DATE:
The Applicant shall assume risks or be liable for all injuries or damages caused by
the opening or excavation of the street or by the failure to properly protect the same, backfill the same,
restore the surface or maintain the surface or by any other action or inactions in connection therewith.
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Street Cut Permit 704 Fourth Street PO (Town of Mills)

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Completed 31 January 2021

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