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Application for Street Opening Permit
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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
*
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 - OTHER INFORMATION
Purposed of application:
Residential
Non-Residential
*
SECTION 6 - Contractor Information (if different from Applicant)
Same As
--Select--
Site Information
Owner Information
Applicant Information
Contractor's Name / Company Name
Street Number
Street Name
City
State
Zip Code
Contractor Phone #
Email
Representative:
SECTION 7 - TYPE OF PROPOSED WORK – ATTACH APPLICABLE PLANS
Check Only One:
Reconstruct / or Overlay Existing driveway
Relocate Driveway
Utility work
Other
Dig Safe Number
Length of Opening (in feet)
Width of Opening (in feet):
Estimated Construction Start Date:
Estimated Construction End Date
Location - Check all that apply:
Roadway
Shoulder
Sidewalk
Curb
Driveway
Stonewall
Would the address to the property change?
Yes
No
*
From Address
*
To Address
*
Why do you need this change?
*
Brief Description of Proposed Work
DECLARATION
By signing below, I hereby acknowledge that I have completely read, understand and agree to the specifications. I have also reviewed the Street opening Moratorium list as identified in the specifications.
*
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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