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Tax 2012C-PT140110 ry ' copy, tl eiappro permit must be on t :e job si att imes 4 ��7 � ��"�� � ? � g � � '' x£ T H` C C i T Y O F °»f � 3 ��� 44p y.'a.31r�.4 �'° � O,PPE LTT Page 11''.6'.4 z Publi o w . ", �� � 1iv ( 61 s 47.,V Ad1Hb k T r . ,4, 0 »Q' o Pcigiri ti 1:F .1` ri X 4 o . ,, t $ t a r n r-s'r;:;)11,f,i.i. .. RIy ' °T-OF-WA ` USE PERM qI APPLICATION x f 0-a1id �') 0 daysfr thi n pr cl D y $ubmit perm its applic non to n neering I?ept,Town+Center,255 Part way Blvd Coppell TX 75019 U _ Date of Submittal: 1 ' /0-i 4 Applicant's Job#I Work Order# 3,2.3 04 3-7 , 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? Y /0 EMAIL ADDRESS FOR SUBMITTAL : engineer(it:col pelltx.gov. Plans provided and approved?(Erosion Control/Safety Fences must be installed prior to beginning work) Project Name/Location or address L©PPell.( .kt r ST er i - limit' Q 0.l) General Contractor Contact# '--° Email address to return approved permit r f ,,, Representative: i, e l t. 'r, Telephone#: ' . `. - r'- 2 �,'' Emergency#: ''4 f• 21 I- 23 oEmail address: SIC k• r el) 'not& 040j.taif',eaiw y (for contact if needed!if email of approved permit is desired/permit cannot be emailed unless complete) Utility Company Represented: II 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 1 set of prints. ,l� .,60111' 5f ec La6141' /A As h/Cs`f' fa Gi-evvi MAl i Gt° A tui). B ' 44 i E a ,;r� at 2 Estf Comp elettot Deate c* "6 1 ;i Catnpretzan eil.i i s CA;V Lion and subn z at f te p.ltion_Vrifiaton Nofte ( page 4):" t s s [*Was City Utility Dept. contacted to locate exist' g underground utilities? Yes 0 No If not, reason Z 04.41V ( y i i fise eQ u t -Sill) * ^ 40 44a eRAQ4 l", D ia,i,4) Is removal of existing streets, alleys or sidewalks necessary? Yes ri No �' t if Yes,project mint 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 972-462-515. r tot 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. E:b, Attach the Franchise Work Order(if applicable)and I set of prints showing the proposed work. Lh es# x estng;fancha i d e tht bdon4 hourprior o begrnntirg work . For City uttlityyocutes,call 972 `4 g h55ldrschednle 4S hotirs prrotto begin rug 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 eng_ineere coppelltx.uov. If 44 want the approved permit returned via email,provide a valid email address on Page 1. <"11 ', . it cannot be email,d utiles• I1 required signatures are present sa /1°' ..di''°°°°..rill.iii' t S'1 u e o I '�lity presentative ' inted Name Date • /. _ -`. '" 0 -1/7 ( -/49 - (4 Signature of C a atrac •epresentative rinted Name Date i ■ Slim r • ty 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 backftlling. Backlit!material must meet City of Coppell standards. Applicant shall ircdernnify 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. I ' -..• 1rr / ' V ert 4 .I < F r � •+.:i5 X:6, 1fy`'Tf. j� - ❑ k ! dF .1 *:,.= ...�: v. it 1. r. S . . lie Dr , :::,.!..,„, i 1 I t €P• sus . \•,�# _� 3 {' J }- r v .-` ''''.;;L..:.4 ''' . _. :1i. 4 aM 4 4 �� S, F •-3 , � h �,r :: ! 4 .x'• 15.141141 t i .. w. !!• i ,.4 .,C:;'°' 3 ' h