Lesley Retail (QT)-PT111007 T H E • C 1 T Y • O F Page 1 of 4
COPPELL
R A s m l$ 9
8RROM BORE / STREET CUT / SAW CUT PERMIT APPLICATION
FOR WORK IN
RIGHT -OF -WAY / EASEMENT
Submit permit application to the Engineering Dept., Town Center, 255 Parkway Blvd.
Date Submitted: /6-6- // Work Order # (if applicable)
PERMIT FEE: $100.00
(No charge to Utility Companies with approved Franchise /ROW Use Agreement)
❑ Plans provided and approved
(Erosion Control/safety fences must be installed prior to beginning work)
Project Name / Location: i - - j,t_yt t,• -c,._ Ch l — 1 j P 13F L T L 1 N k 'RD G D V 1) e j o e,
Company Name: f rat- 411, S ate►
Address: /' y 1
Telephone #: 972- 8' y'J / 6 Emergency Telephone #: J 533 6
Permit issued to (Contractor Name)
Utility Company Represented:
❑ Oncor Electric Delivery ❑ Atmos Energy ❑ Verizon ❑ SBC / AT &T
❑ Time Warner Cable ❑ CoSery Elec /Gas Other *
* If "Other" is checked, please note that franchise or right -of -way use agreements will be required.
General Description off Work (provide copy of approved plans):
IT d /� T'vr' .c C/ — � ` r 7 / ,4
Was contact made with City and /or utility companies to locate existing utilities?
if NO, Reason: YES NO ❑
➢ Is removal of existing streets, alleys, or sidewalks necessary? YES ❑ NO [y
if YES, must have City inspection prior to concrete replacement
A COPY OF THE APPROVED PERMIT MUST BE ON THE JOB SITE AT ALL TIMES.
Dry Bore / Street Cut / Saw Cut Permit Page 2 of 4
Representative(s) of the Contractor must adhere to all construction standards approved by the City of Coppell, which
includes but is not limited to: Erosion Control Ordinance, compaction requirements (density tests may be required at
the applicants expense) and barricading according to the Texas Manual on Uniform Traffic Control Devices.
Area(s) affected must be restored to as good condition as before the commencement of work (grading, drainage,
vegetation, and erosion control).
➢ Any excavation requiring closing of a street /alley must be reported prior to closing to the following:
Police Department CO 972- 304 -3600
Fire Department @ 972 - 304 -3500
Street Department @ 972 -462 -5150
Engineering Department a 972 - 304 -3679
➢ Attach barricade plan / trench safety plan if a lane or street closure is required.
NOTE: Street closures are allowed from 9:00 a.m. until 4:00 p.m. ONLY unless otherwise approved by City
Engineer.
- Attach Work Order (franchise only).
r Contact must be made with City and utility companies to locate existing utilities 48 hours prior to beginning of
work.
Signature of Utility Company Representative Printed Name Date
�,�!►� v rz` / --o -- /
ignature o' : actor Re. - . tive Printed Name Date
Si • f 'ty Representative Printed Name Date
(Application with original signatures needs to be submitted to the Engineering Department before approval.)
• Comments:
➢ NOTE: Notify City Inspector at 972 - 304 -3679 prior to beginning work and prior to backfill for concrete, trench, ditch and
open pit inspections. Backfdl must meet all construction standards approved by the City of Coppell.
Applicant shall indemnify and forever hold harmless against the City of Coppell each and every claim,
demand or cause of action that may be made or come against 11 by reason of or if any way arising out of the
closure, blocking, excavating, cutting, tunneling, or other work by the applicant under permit from the City,
if such permit is granted.
FILE LOCATION: K:\Projects\Div 08 Dal las\09 69\Civil\0969 Pothole Plan.dwg TAB NAME:Pothole USERAmckay SAVED:9/1/2011 4:42 PM PLOTTED:9/1/2011 4:44 PM
I > I m I 1 0 1 m I -M I e-, I — I I I I I
m
m
M
n
IF
z