ST1002-PT130211 02-11-1 3 P09:97 RCVD
A copy of the approved permit must be on the job site at all times.
CC:Applicant P f04
COPPELL Page o
public.Work Rev. 02/2012
Original to LF/FILE
, '''', .: ,RIGHt- WAY USE PERMIT APPLICATION
, r, povit „ , ,,, . ... , ,..
daysikorn the date a fapprovaL
I A ' - 'Permit valid/9r 90-
Submit permit applicatinn to Engineerina Dept Town Center;255 Parkway Blvd.Coppell TX 75019
Date of Submittal: 2 -ft- 13 Applicant's Job #/Work Order# 3 (
PERMIT FEE: $100 (No charge to franchise utility companies with ROW Use Agreement)
. ..---:—
Refer to City of Coppell Ordinance No.2001-944. Certificated Telecom Provider? 1
E Ai -kit,ADDRESS FOR SI:131\11TTAI, : en zittect-it con Iclitx,gov.
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Plans provided and approved?(Erosion Control/Safety Fences must be installed prior to beginning work)
Project Name! Location or address 040 1-Oveti Cork It f? / 4-r gi9e,*1-(.41'e,C
General Contractor - Contact #
Email address to return approved permit —
',.•.j, .,,.. Representative: (C2if*-"e"c7/e- ,igi 6 1<
C g Telephone#: -‘ ,i -2 - /- ' 2..5"C Emergency #: 464- 26/-5-45'37
,..
--':, ::•,'' Email address: rkK . t..e.--(d.\-,5 e... oiveoR,
...., :..,,,
L-. (for contact if needed/if email of approved permit is desired/permit cannot be emailed unless complete)
Utility Company Represented:
s'fiit: Oncor Electric Delivery 0 Atmos Energy 0 Verizon 0 AT&T/SBC
0 Time Warner Cable 0 Time Warner Telecom 0 Other
Gmeral Description of Work(in accordance with Ordinatic001-944) Provide I set of prints.
ie,.1041,9-re / -77(40aet/he-4,- ietik)ott-co ive1064-1-1--e i /./e..upocte.--
/4 `/1,42R7-Y.,, re/1.6kt,-; . -.)4.'cri:A,)4 0-ii.:.4-1)Pitz ../ e--.)«..srcw6. 31*/7kez 4..,4))44tTJA-
1- i, 7 Piecept., y P" , iii6 . if i9ve- eb"oPPtif: , 11/1,L__,3.(;)CiN
itit, c("1-tr LtitI('Ttes •-7:1.3 14-1iey
,
Estimated Startl)ate 04'4.5 - f3 Estimated Completion Date* 3 -.5 - 13
*completion requires inspection and submittal of Completion Verification Notice (page 4).
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Was City Utility Dept. contacted to locate existing underground utilities? Yes V I No IM:
If not, reason rftz,,LA1,-e4 ',vitt & jo.,..0,--E-.0 ",,,,,,,,,, )
44? 0144.5 or 40.4.-)fig.t...tift,..) 511)124;
1:›Is removal of existing streets, alleys or sidewalks necessary? Yes No Mr'
if Yes,project must hare City inspection prior to concrete replacement.
Right-of-Way Use Permit Application 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
((tensity 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.
*.--- 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.
Attach 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 beginningl,vork.
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 engineeralcopoelltx.gov.
El> If riu want the approved permit returned via email,provide a valid email address on Page 1. <il
•:rant cannot 1,- etailed unless# equired signatures are present.
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Algrer,,d : ,„,....••""
Sign' ire of Li * ty oii,-,ny Repre -.•tatiJc Printed Name Date
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. ignature of Contr , .
-presentative Printed Name Date
Signature of City Representative Printed Name Date
COMMENTS:
NOTE: Notifj.Engineering Dept. at 972-304-3679 prior to beginning work and fOr open trench, ditch or pit
inspection prior to backlit/Mg. Backlit/material must meet city of Coppell standards.
r4;licant shall indemnify and fbrever hold harmless the City of Coppell against each and even.'claim, demand, or
i eatme of action that may be made or come against it by reason of or if iii any.a.tyty arising out ty:the closttre, block log.
excavation,cilia*, tunneling, or tallier work performed by the applicant wider pct the City i l such permtt is
granted.
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