| 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 |
| 3 Scope and restoration |
| ☐ Excavation ☐ Boring ☐ Utility installation ☐ Repair ☐ Other\nDescribe 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\nTraffic and pedestrian access arrangements |
| 4 Attachments and applicant certification |
 Site plan showing scope of work attached\nOther materials provided for City review, as applicable\n☐ Traffic control plan  Restoration detail ☐ Insurance ☐ Bond ☐ Other\nI 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.\nApplicant 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
