Local Diner-PT130220 02 'l9-13Pu3:44 RCVD
A copy of the approved permit must be on"the lob site at all times
Applicant O.L PELL Page 1 of 4
Public Works " . Rev 02/201?
Original toLl/FILE, 4 ` m 5
p RIGHT-OF-WAY USE PERMIT APPLICATION
/;',,,,i I Permit valid fir 90 dayy 'Om the date of appioval.
Submit permit application to Engineering Dept.,Town Center,255 Parkway Blvd.Coppell TX 75019
Date of Submittal: ` 19' t 3 Applicant's Job#/Work Order# -5 !' 70 s-
PERMIT FEE: 5100 (No charge to franchise utility companies with ROW Use Agreement)
Refer to City of Coppell Ordinance No.2001-944. Certificated Telecom Provider? V /9
EMAIL ADDRESS SS FOB SUBMITTAL : engineer copt)elf±x.tov
t
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Plans provided and approved?(Erosion Control/Safety Fences must be installed prior to beginning work)
Project Name/Location or address LotAt Diver eer»v .2- Si Lis .- 1-145f; l SF. L1";
General Contractor Contact# -
Email address to return approved permit elc „ri7e,414,39 e.nu eve,C06,
a N Representative: / i %
a '.
Telephone#: 40-2 /-5-2,53 Emergency#: 469-.26 I- Sz
< r Email address: 't'iak , cia-146443e oveop. c-s.
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(for contact if needed if email of approved permit is desired/permit cannot be emailed unless complete)
Utility Company Represented:
xe Oncor Electric Delivery 0 Atmos Energy 0 Verizon 0 AT&T/SEC
0 Time Warner Cable 0 Time Warner Telecom 0 Other
Gmteral Description of Work (in accordance with Ordinance 2001-944)Provide 1 set of prints.
Kervadx A S f L-T S t^1;N.1 i1 all , I S".. ' or' ST. L i. <ecopmfe Y ,i-0s761 t
L1 Lf $erf3M raj 1 i/so t Sf L`I. See.."- 0912p , •/QI'-S7' 10
A'L\. t'i vit. IrUUtZi..,.
Estimated Start Date . . -' ""13. .:".Estimated'Completion Date* 3 ` 2-5- 1 3
*Completion requires"inspection and submittal of Completion Verification Notice (page 4).
E> 'as City Utility Dept. contacted to locate existing underground utilities? Yes 0 No
If not, reason RL L» Gr'v IL RV rd-Et`,-S1 Act- 1 1` trm(Lj,
E>Is removal of existing streets,alleys or sidewalks necessary? Yes [I No
if Yes,project must have 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
(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 972462-5155.
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. 972-304-351.2
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.
E> Attach the Franchise Work Order(if applicable)and 1 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 n;coppelltx.aov.
E> If ', want the approved permit returned via email,provide a valid email address on Page 1
Fermi ,e emailed unless *, equired signatures are present.
Si' e of(Utility 's &ny Representative Name inted Nae
ii I" Date
-,,,, --- .� c 1/10 - I t- 13
,ignature of `ontr . 'epresentative ' Printed Name Date
(4.,_ --�� ,;i /'f,/,, 2(Z4='ij
ature of City Representative Printed Name Date
COMMENTS:
N'O:TE:Notify Engineering Dept. at 972-304-3679 prior to beginning work and for open trench,ditch or pit
inspection prior to backfilling. 13ackfill material must meet City of Coppell standards.
Applicant shall indernn,&and forever hold harmless the City of Coppell against each and every claim, detnaad. or
cause of action that may be made or come against it by reason of or if in any riay arising out of, closure,e, htccl,na,
excavation, cutting, tunneling, or other work perfornred by the applicant under permit from the City, ifsue such permit is
granted.
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