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| THE CITY OF BALCH SPRINGS\nGROWING COMMUNITY\nRight of Way Permit Application\n13503 Alexander Road | Balch Springs, TX 75181 | 972-286-4477\nComplete both pages and attach a site plan showing the location and scope of work. Submit for City review before beginning work. Use additional sheets if needed.\nROW permit fee: $50.00\n1 Applicant and responsible parties | |
| Applicant or company name | |
| Mailing address, city, state and ZIP | |
| Contact name and title | |
| Phone | |
|---|---|
| Contractor or utility owner | City registration number, if applicable |
| On-site supervisor | 24-hour contact phone |
| 2 Work location and schedule | |
| Work address or location | |
| Street limits / nearest cross streets / side of street | |
| Project name or reference number | Utility or facility owner |
| Proposed start date | Proposed completion date |
| Proposed workdays and hours | |
| Check all affected areas | |
| ☐ Street ☐ Sidewalk ☐ Alley ☐ Parkway / verge ☐ Other | |
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GROWING COMMUNITY
Work Details and City Review
13503 Alexander Road | Balch Springs, TX 75181 | 972-286-4477
Applicant / company
Work location
3 Scope and restoration
☐ Excavation ☐ Boring ☐ Utility installation ☐ Repair ☐ Other Describe proposed work, equipment and materials
Excavation / bore length, width and depth Pavement or sidewalk area affected
Restoration materials and method Anticipated restoration date
☐ Lane closure [F8] Street closure Sidewalk closure No closure proposed Traffic and pedestrian access arrangements
4 Attachments and applicant certification
Site plan showing scope of work attached Other materials provided for City review, as applicable ☐ Traffic control plan Restoration detail ☐ Insurance ☐ Bond ☐ Other I certify that the information submitted is accurate to the best of my knowledge. I understand that this application is not a permit and that work is subject to City approval and applicable requirements. Applicant signature Printed name and date
5 City use only
Received: ____________ Permit no.: ____________
ROW fee: $50.00 Paid: $ ____________ Date paid: ____________ Receipt no.: ____________
Insurance / bond review: ___ Approved dates: ___
Conditions / attachments: ___
Authorized by: ___ Signature: ___ Date: ___
ROW application | 2 of 2