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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