477 & 505 Houston St/Coppell A copy of the approved permit must be on the job site at all times.
T H C • C I T V . 0 F
CC:Applicant COPPELL Page 1 of 4
Public Works Rev. 02/2012
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RIGHT- - Y C
Permit vad for USE 90 days frPERMIT om the date of APPLIATION approval.
Submit permit application to Engineering Dept.,Town Center,255 Parkway Blvd.Coppell TX 75019
Date of Submittal: ,2_4-_2741u....../.5 Applicant's Job#/Work Order#
PERMIT FEE: $100 (N harge to franchise utility companies with ROW Use Agreement)
Refer to City of Coppell Ordinance No.2001-944. Certificated Telecom Provider? Y / N
EMAIL ADDRESS FOR SUBMITTAL: enginecr(dcoppclltx.gov
Plans provided and approved?(Erosion Control/Safety Fences must be installed prior to beginning work)
/7 2
Name
Project ame/Location or address G,1 �1,f,,�/
General Contractor �ksA� my, Contact#,r2,/,/3S3/-SB�
Email address to re urn approved permil/6,4 .45 ��.,,i_c , Cc:2
Representative: j e3.-/d'j„v -
-t Telephone#: Emergeit y#:
go Email address:XL,d,
(for contact if needed/if email of approved permit is desired/permit cannot be emailed unless complete)
Utility Company Represented:
O'Oncor Electric Delivery 0 Atmos Energy 0 Verizon 0 AT&T/SBC
0 Time Warner Cable 0 Time Warner Telecom 0 Other
General Description of Work(in accordance with Ordinance 2001-944)Provide 3 sets of prints.
Estimated Start Date,2L.Twt .—Estimated Completion Date* 2 /eu8- /3
*Completion requires inspection and submittal of Completion Verification Notice(page 4).
$Was City Utility Dept. contacted to locate existing underground utilities? Yes Or No
If not, reason
*Is removal of existing streets,alleys or sidewalks necessary? Yes ® 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 972-462-5155.
I+ 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
4 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.
4 Attach the Franchise Work Order(if applicable)and 3 sets 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(7a,coppelltx.gov.
I* If you want the approved permit returned via email,provide a valid email address on Page 1.
Permit cannot be emailed unless all required signatures are present.
Signature of Utility Company Representative Printed Name Date
Signature of Contractor Representative Printed Name Date v
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S ••� ity Representative Printed Name Date
4 COMMENTS:
NOTE:Notes Engineering Dept.at 972-304-3679 prior to beginning work and for open trench,ditch or pit
inspection prior to backfilling. Backlit'material must meet City of Coppell standards.
Applicant shall indemn j and forever hold harmless the City of Coppell against each and every claim, demand, or
cause of action that may be made or come against it by reason of or if in any way arising out of the closure, blocking,
excavation, cutting, tunneling, or other work performed by the applicant under permit from the City,if such permit is
granted
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