GROWING COMMUNITY

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: ___

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