The following application shall be used:
1. Name and Address of Applicant: ________________________________________________
2. Telephone Number of Applicant: ________________________________________________
3. Reason for Street Cut: _______________________________________________________
________________________________________________________________________________
4. Is excavation (removal of surface and sub-surface materials) required: ___ If so, please explain:
________________________________________________________________________________
5. Size of street cut and excavation (length, width, depth): ________________________________
6. Name/address/telephone number of person or firm performing the cut and excavation:
________________________________________________________________________________
a. Name and title of representative in charge of cut and work: __________________________
7. Date of commencement of work: _____ 8. Date or anticipated date of completion of work: __
9. Name/address/telephone number of person or firm performing street reclamation:
________________________________________________________________________________
a. Name and title of representative in charge: ________________________________________
b. Describe Method of Reclamation: _______________________________________________
10. $25 permit fee submitted: _________ 11. Plat map or scaled drawing submitted: _________
12. Cash Bond: _____ (check) 13. Performance Bond: ___________ (check)
14. Applicant is: ___ Individual ___ Firm ___ Corporation ___ Association ___ Partnership
___Public Utility
APPLICATION FOR STREET CUT PERMIT: Applicant, by signing below, in consideration for the issuance of a street cut permit, agrees to hold harmless and indemnify the City of Brazil, its officers, employees, agents and representatives against any and all damages and claim for damages which may be asserted against the city and the like by reason of or arising out of the street cut or excavation and any work done as a result thereof for which a permit has been issued.
Date: ________________ Applicant: _______________________________________________
Approved: _______________________ __________________________________________
Clerk-Treasurer Street Department Supervisor
Permit No. _______ Issued _______ (date) Permit Denied ___________________
Reasons: _______________________________________________________________________
(1982 Code, Title IX, Appendix)