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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	Email
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: ___

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