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CITY Utility Connections/Right of Way Permits Office <br />ADDRESS <br />Telephone (XXX) XXX-XXXX <br />APPLICATION FOR RIGHT OF WAY PERMITS <br />Excavation Permit <br />Obstruction Permit <br />Attached Plan Submitted by (Applicant): <br />El Joint Application (Company Names): <br />GSOC Registration #: <br />1 <br />Plan ft: <br />Project #: <br />Location: <br />From and To (Address/Location): <br />Applicant: <br />Address: <br />24 Hour Phone: <br />City: <br />State: <br />Zip: <br />Contact Person: <br />Cell Phone #: <br />Work Phone: 24 Hour #: <br />Pager #: <br />General Contractor. <br />GSOC Registration #: <br />Work Phone: 24 Hr. #: <br />Contact Person: <br />Work Phone: <br />Home Phone: <br />Pager/Cell #: <br />Sub Contractor #1: <br />GSOC Registration #: <br />Sub Contractor #2: <br />GSOC Registration #: <br />1,4144W4raiKa$.5‘4:lood*V-,9.10W' <br />4F4gir 'WifittoW -.114.104,ft.80.1WASINA-INEMASME00::::::.= <br />Cable TV <br />Gas: <br />Cooling <br />High Pressure <br />Traffic <br />Low Pressure <br />Heating <br />Water <br />Conduit (Size & Kind): <br />Electrical, Voltage: <br />Sewer <br />Telecomm. <br />Fiber <br />Other. <br />Cable (Size &Type): • <br />MOMEASSONOMNS Wittaa <br />T ',Replacement Repair <br />ELAMOMMUMMANagaMOVEOM <br />, I <br />New <br />A'WeLgsd.1 <br />'Other. <br />1 <br />Trench <br />Hole <br />1 'Chamber <br />Bore(Specify) <br />Aerial <br />Plow (Specify) <br />Other. <br />FliTABROMME::=1::::SMOUREINNWEINE:.... <br />Excavation Size: <br />Length: <br />Width: <br />- <br />Depth: <br />Total Linear Footage Installed: 1 <br />1 <br />ROW being used: <br />Driving Lane <br />Parking Lane <br />Sidewalk <br />Blvd. <br />Type of Material: <br />Concrete . <br />Bituminous <br />Gravel <br />Sod <br />I {Reid Grass 1 <br />'Trees A iShrubs <br />Structures: <br />Curb & Gutter <br />Sidewalk <br />Signals <br />Other.. <br />Shoulders: <br />Bituminous <br />Gravel <br />Road Signs <br />Culvert <br />• I - 'Other: <br />Estimated Starting Dates: <br />ergalinginigiNEMMONZAMMUIRINSESP::...11,.. <br />Weekend Dates: <br />Estimated Ending Dates: <br />After Hour Dates: <br />Applicants Signature: <br />Date: - <br />Date Received: <br />Review Committee <br />Yes <br />No <br />Approval Date: <br />Permit Number. <br />Perrnit97 1/30P98 <br />7:17 AM <br />