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APPLICATION FOR Driveway Entrance
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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
Applicant Name
Street Number
Street Name
City
State
Zip Code
Telephone
Email
SECTION 4 - MAILING ADDRESS
Same As
--Select--
Site Information
Owner Information
Applicant Information
Street Number
Street Name
City
State
Zip Code
*
SECTION 5 - Contractor/Excavator Information
Same As
--Select--
Site Information
Owner Information
Applicant Information
Mailing Information
Contractor Name
Street Number
Street Name
City
State
Zip Code
Office Contact Person
Office Tel
License Number
Expiry Date
Email
*
SECTION 6 - LIABILITY INSURANCE INFORMATION
Name of Liability Insurer
Street Number
Street Name
City
State
Zip Code
Liability Insurer Contact Name
Liability Insurer Telephone
SECTION 7 - Description of Proposed Work
*
Check Only One:
Reconstruct and/or Overlay Existing Driveway
New Driveway or Opening*
Relocate or Widen Existing Driveway*
Major Way Resurfacing or Reconstruction*
Other
*Applicant must submit site plan with application
*
Dig Safe Number
*
Date Valid
*
Proposed Construction Dates
*
From
*
To
Driveway Dimension Guidelines
See Division 4 Right of Way Regulation
.
Check all that apply and sketch locations on detail
Existing “U” shaped driveway
Existing multiple driveway openings
Curbing/berm
Granite/Stone Bound(s)
Catch Basin(s)
Utility Gate(s)
Sidewalk/Ramp
Utility Pole(s)
Tree(s)
Other
*
Existing Width
-ft
Proposed Driveway Width
-ft
Existing Driveway Area
-sq. ft.
Proposed Driveway Area
-sq. ft.
Proposed Radius(if applicable)
-ft
*
Proposed Width
-ft
Proposed Grade
-ft
Proposed Angle
-ft
*
Brief Description of Proposed Work
SECTION 8 - 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 9 - DECLARATION
The undersigned hereby certifies that he/she has read and examined this application and that the proposed work is accurately represented in the statements made in this application. I understand that no work shall be performed prior to the issuance of an Approved Permit and that all work shall be executed in accordance with the terms and conditions of said permit (and all other applicable laws and bylaws in effect on the date of issuance). I understand that deviations from the approved permit plan that have not been subsequently approved in writing by the authorizing Agency shall result in immediate revocation of the permit, issuance of fines and require restoration of disturbed area to pre-construction conditions.
*
I do hereby 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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