The undersigned is applying for a permit to enter in upon and work in portion of Town Right of Way at the

 

following location: __________________________________________________________________________________

 

For the purpose of: _________________________________________________________________________________

 

The undersigned acknowledges that they have read the conditions listed herein and accept said conditions in consideration of granting this permit or license for the purpose(s) herein set forth, and agree the right of entry is subject to terms of the Town’s interest in said right of way.

Applicant signed this _______________ day of __________________________________

 

Name of Contractor or Owner _________________________________________________

Agent’s address____________________________________________________________

Contractor or Agent_________________________________________________________

 

Contractor or Contractor or Agent’s Signature ____________________________________

 

Agent’s phone no.__________________________________________________________

 

THIS APPLICATION is approved with the following directions, requirements and specifications:

1. All work performed within Town right of way shall comply with Town of Quartzsite construction

standards and specifications.

2. Public Works (Phone (928) 927-4561) shall be notified 24 hours in advance of all work.

3. Newly paved or overlaid streets or alleys shall not be open cut for a period of two years.

4. Water/sewer taps shall be inspected during normal business hours.

Contractor will not back fill until the water or sewer lines have been inspected.

5. All other work to commence within the Town of Quartzsite right-of-way shall be inspected

during normal business hours ONLY.

6. The applicant must call the Town of Quartzsite Public Works Department

(Phone (928) 927-4561) and Building Department (Phone (928) 927-4414 and Town Police

Phone (928) 927-4644) if any work involves closing a street or alley to vehicular traffic.

 

_____________________________________________________________________________________________________

Permit and License

 

No._______________________________________                   Fee $ ____________________________

A permit and license is hereby issued to the foregoing applicant for the purpose contained in the application and upon the expressed condition that every agreement and covenant therein contained is faithfully performed and said work to be performed in accordance with the approved plans and specifications, or as stipulated.

Date Issued __________________________ Construction work or use to be completed by   Date__________________________

 

 

                                                 

TOWN OF QUARTZSITE

 

____________________________________________   ________________________________________   __________________________________

Public Works Director                                                                 Utilities                                          Planning & Zoning Department