APPENDIX A: RIGHT-OF-WAY USE APPLICATION

Town of Albany

210 East State Street

Albany, IN 47320

Telephone: [phone]

Fax: [phone]

Application Date:                                                       Phone #:                                                               

Owner’s Name:                                                          Fax #:                                                                  

Mailing Address:                                                        Cell Phone #:                                                        

                                                                                 Utility ID:                                                             

Contractor’s Name:                                                     Phone #:                                                              

                                                                                 Fax #:                                                                  

Mailing Address:                                                         Cell Phone #:                                                        

                                                                                 Utility ID:                                                             

Location of Right-of-Way Use:                                                                                                                

Type of Right-of-Way Use:                                                                                                                     

            Be specific to the use as possible

INVASIVE

[ ] Excavate or dismantle of town facilities drawing or specifications required

[ ] Restoration of the town facilities

[ ] Type of restoration

   [ ] Sod

   [ ] Sidewalk

   [ ] Pavement

   [ ] And the like

(A)   General information of contractor requesting permit.

(B)   A map of the proposed work to be performed. The map shall include street address, where in the right-of-way work is being performed, north indicator and/or cross road if possible. If service line is to be ran to the existing structure, show where service line comes from the main line and goes to the structure.

PERMIT QUESTION

Is work being performed in:

Grass                                     

Gravel                                   

Asphalt                                  

Cement                                  

All repairs shall be restored when finished, to same or better condition, as before commencing work.

THE PERMITTEE SHALL NOTIFY THE CLERK-TREASURER OFFICE 24 HOURS PRIOR TO THE TIME HE OR SHE INTENDS TO REQUEST A FINAL INSPECTION.

PERMIT INFORMATION

Start Date:                                                     Completion Date:                                                               

Print Applicant Name                        Sign Applicant Name

Address                                 Phone

PERMIT FEES

                                 Permit fees - $25

(Ord. 2005-13, passed 6-13-05)