Ridgecrest-PT121113 of the approved permit mast be on tfie job site at all times-
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RIGHT-OFW:AY US*:PERMITAPPL,IICATION
pennilVaridibr 96 days fivm the_ciare of appro a, ,
t application t g; 255 Parkway Blvd!cl-opOi!e:-11"il'2X A7gol.24-75 R C VD
B B u.mit permit application' ' to En lneering Dept,Town Centel',
Date of Submittal: II '7---(9- Applicant's Job 4 I Work Order 4 3 I
PERMIT FEE: S100 (No charge to franchise utility companies with ROW Use Agreement)
a-)
Refer to City of Coppell Ordinance No.2001-944. , Certificated Telecom Provider? Y. 6,
ADDRESS FOR SUBMITTAL : enaitieer a co) ( .., . work)
Plans provided anEdNal;\;Irlo'N,j'ed?(Erosion Control/Safety Fences must be installed prior to beginning i
_
PfPlAtC
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Project Name I Location or address . .1)66612e1- 1101:#11.' Pei/hove (.17t-3//..pvt.4.+W4.41
General Contractor /1,17.14 Contact#
Email address to return approved permit Ock, cie ridiA,.-A JP 12,,v6=JZ,4'0,4,
,
>, Representative: i' .. _ ' 't l'is
Telephone#: 2. 14-g";-1314 Etnergency#: 461-.1‘I-.52.5:5-
Email address: if . /dr' tQ.oitleoic, c I)ill
(for contact if needed/if enfiilleolappii-oe'v'ed permit is desired/permit cannot be emailed unless complete)
Utility Company Represented:
Oncor Electric Delivery 0 Atmos Energy 0 Verizon 0 AT&T/SBC
0 Time Warner Cable 0 Time Warner Telecom 0 Other
• tion of•VV/ik(in accordanc,nelveitthit.cIridinian,i)01„...ce 2001-944) Provide 1 set of prints.
Ge eral Description .,„. AziLl'i-itez -- A-1e
ii e 1::,W
erho V .6(4•5/
- )2.
Estimated start Date fk......,9z.. -/2 Estimated Completion Date, 1/.30
*completion requires inspection and submittal of Completion Verification Notice(fif‘ige 4)
underground Dept. contacted to locate existing der.eg,rotiunzd .ttilities? Yes Ej No
Was City Utility. Depo __ . .,1 ft e geat,feirev 4
If not, reason Lpo,4. 1-ES_kV(1 L7 jA) _ .
yes E__:, No g
Is removal of exisatiiiiegl.2str7-ce4:s, :illyf or s .(1,..ewalks. necessary?
if Yes,project must Irene City inspection prior to concrete replacement.
Right-of-Way Use:Permit Application Page 2 o1,1
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 applicant's expense) and barricading according to the
Texas Manual on Uniform Traffic Control Devices.
Affected area must be restored to same condition as before the commencement of work
(grading,drainage,vegetation and erosion control).
To schedule a Public Works final inspection as required on Page 4,call 972-462-5155.
E> Any excavation requiring the closing of a street/alley must be reported to the following prior to closing
Police Dept. 972-304-3600 Fire Dept. 972-304-3512
Street Dept. 972-462-5150 Engineering Dept. 972-304-3679
- > Attach a barricade plan or trench safety plan if a lane or street closure is required. NOTE: Street
closures are allowed from 9:00 a.m. until 3:30 p.m. ONLY unless otherwise approved by City Engineer.
EAttach the Franchise Work Order(if applicable)and I set of prints showing the proposed work.
Locates for existing franchise utilities must be done 48 hours prior to beginning work.
For City utility locates,call 972-462-5155 to schedule 48 hours prior to beginning work.
This application with signatures of Franchise and Contractor representatives must be submitted to Engineering
Department for approval prior to beginning work.Submittals by email should go to engineer: coppelitx.eov_
If you want the approved permit returned via email,provide a valid email address on Page 1.
Permit cannot be ernailed unless all required signatures are present.
d< fietA / -, '- .
Signat re of Utility Co i�:� Representative Printed Name Date
/1- -I
Signature of antra epresentative Printed Name Date
c �� PYlcv ►mot. C=- Arm-.
Si !rature o 'ity Representative Printed Name Date
COMMENTS:
NOTE:Notify Engineering Dept. at 972-304-3679 prior to beginning work and for open trench, ditch or pit
inspection prior to backf lling. Backfill material must meet City of Coppell standards.
Applicant shall rnderrmif and forever hold harmless the City of Coppell against each and every claim, demand,or
cause of action drat may be made or cornet against it by reason of or if in any way arising out of irk closure, blac idns;,
excavation, cutting, tunneling, or other work performed by the applicant under permit from the City, if such permit is
granted
Page 4 of 4
T H E . CIT Y • OF
COPPELL
5 k
UTILITY RELOCATION IN RIGHT-OF-WAY OR EASEMENT
COMPLETION VERIFICATION NOTICE
Contact City of Coppell Public Works Division at 972-462-5155 to schedule an inspection
with Utility & Streets personnel to verify that your project has been completed to City of
Coppell specifications. Failure to schedule verification inspection may delay future projects.
Franchise Utility Name
Project Location / Applicant's 'Work Order # (if applicable)
Sub-contractor Company Name
24 hr.Contact Number
Date of Verification Appointment
Time of Verification Appointment
INFORMATION BELOW TO BE COMPLETED BY CITY OF COPPELL PUBLIC WORKS PERSONNEL
Inspected by of UTILITIES Maintenance Division on
and found to be acceptable /not acceptable because
Follow-up needed? NO/ YES Follow-up scheduled for
Inspected by of STREETS Maintenance Division on
and found to be acceptable /not acceptable because
Follow-up needed? NO / YES Follow-up scheduled for
•
A copy of this completed notice is to be provided to:
City of Coppell Engineering Dept.
255 Parkway Blvd., Coppell TX 75019
Office: 972-304-3679 Fax: 972-304-3570