APPENDIX A: EXCAVATION PERMIT

NAME:   _________________________________________________

FIRM NAME:   _________________________________________________

ADDRESS: _________________________________________________

CITY/VILLAGE: ____________________   STATE: __________   PHONE: _________________

LOCATION OF PROPOSED EXCAVATION: _____________________________________________

___________________________________________________________________________________

____________________________________________________________________________________

NATURE OF EXCAVATION: __________________________________________________________

___________________________________________________________________________________ ____________________________________________________________________________________

BONDING COMPANY:

NAME:   _________________________________________________

ADDRESS:   _________________________________________________

CITY/VILLAGE: ____________________   STATE: ________ PHONE: _________________

AMOUNT OF BOND: $___________________

PREVIOUS EXPERIENCE (LIST CITIES AND/OR VILLAGES)

CITY/VILLAGE            CITY/VILLAGE OFFICIAL

1.   ______________________      _______________________________________

2.   ______________________      _______________________________________

3.   ______________________      _______________________________________

4.   ______________________      _______________________________________

   I have read the municipal law with regard to excavations and my firm or company intends to fully comply with the Street Regulations Code provisions.

_________________________________________________

(Applicant's Signature)