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APPLICATION FOR Excavation in Right of Way
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SECTION 1 - SITE INFORMATION
No
Street Address / Owner
*
Street Name
*
Street Number
*
Parcel Number
Zone
*
Street Name
*
Street Number
*
Parcel Number
Zone
Unit Number
Location Description
SECTION 2 - OWNER INFORMATION
Same As Site Information
Owner Name
Street Number
Street Name
City
State
Zip Code
Telephone
*
Email
*
SECTION 3 - APPLICANT INFORMATION
Same As Owner
Company Name
Applicant Name/ Office Contact Person
Bus. Street Number
Bus. Street Name
Bus. City
Bus. State
Bus. Zip Code
Office Telephone
Contact Person Email
*
SECTION 4 - MAILING ADDRESS
Same As
--Select--
Site Information
Owner Information
Applicant Information
Street Number
Street Name
City
State
Zip Code
SECTION 5 - LIABILITY INSURANCE INFORMATION
Operator
Massachusetts Hoisting License #
Certificate #
Policy Expiration Date
*
Name of Liability Insurer
*
Street Number
*
Street Name
*
City
*
State
*
Zip Code
*
Liability Insurer Contact Name
*
Liability Insurer Telephone
SECTION 6 - Description of Proposed Work
Length of Opening (in feet):
Width of Opening (in feet)
*
Location (check all that apply):
Roadway
Shoulder
Sidewalk
Curb
Driveway
*
Construction Start Date:
Construction End Date:
*
Maximum of thirty (30) calendar days from issue date to complete proposed work.
*
Dig Safe Number:
*
Date Valid:
*
Brief Description of Proposed Work
SECTION 7 - Property Owner Certification
I am the
Owner
Agent
I,
as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this Right-of-Way permit application. I understand that the permit application will not be accepted or the permit granted until all applicable fees are paid in full. No work shall be performed prior to the issuance of an Approved Permit.
I further certify that the Town of Milton will not be responsible for future maintenance, upkeep or repair of the area subject to the approved permit that is within the Town Right-of-Way.
*
Property Owner's Email
OR
Copy of Signed Contract to be attached after submitting application
I do hereby certify under the pains & penalties of perjury that the information provided above is true and correct.
Date
Select date
SECTION 8 - DECLARATION
*
I have read and understood the following
instructions
. I do hereby agree to abide by the same under the pains & penalties of perjury.
*
I do hereby also certify under the pains & penalties of perjury that the information provided above is true and correct.
Date
Select date
* Indicates Mandatory Field.
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