Tax 2011B-PT121112 t Ft C 4 c 4: T Page l of 4
COPPE
4
DRY 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.or by e-mail to engineer @coppelltx.gov(see button below
Date Submitted:WOMPUTEEMEMTV 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: Soo bloc of west.wooel & Vanbebber
Company Name: Kerizon:
Address 113z > M a7,Iew�sville tx 7so77
Telephone#:572 318 5186
p : .,..� . ._.: � Emergency Telephone#:Nt.E .. .. _...,. H .._ .e
Permit issued to(Contractor Name) ., ,,;_ . ... __.._ ._..._,,: ?.
Utility Company Represented:
(� Oncor Electric Delivery C Atmos Energy R Verizon C SBC/AT&T
[ Time Warner Cable C CoSery Electric/Gas C Other
*If"Other"is checked,please note that franchise or right-of-way use agreements will be required.
General Description of Work(provide copy of approved plans):
'E7erizon will attempt to.Mplace# a new road bore where the city contractor bas
Was contact made with City and/or utility companies to locate existing utilities?
if NO,Reason: Yes C No ()
>Is removal of existing streets,alleys,or sidewalks necessary? Yes C No (:)
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 I 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 @ 972-304-3600
Fire Department @ 972-304-3512
Street Department @ 972-462-5150
Engineering Department @ 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).
Contact must be made with City and utility companies to locate existing utilities 48 hours prior to beginning of
work. •
Printing your name indicates your acceptance of the terms and conditions of this form:
Pa1,41 tttssenhezmer ... .. 1/0.9/2012;
Signature of Utility Company Representative Date
Charles's Dear.. ...:. .. .. .'::: 11/097:2 012
Signature of Contractor Representative Date
ZZ-1....
Signature of City Representative Date
(Application with signatures needs to be submitted to the Engineering Department before approval.)
>Comments: 1 . ., i i 1 7 6.'� -70
A,/ Cc90Td ►fr-'Noh tij CI ii,/ Cow/r
>NOTE: Notify City Inspector at 972-304-3679 prior to beginning work and prior to backfill for concrete,trench,ditch and
fY tY P P 9 9 P
open pit inspections. Backfill 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 it 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.
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