Road & Lane Closure for Utility Companies Permit Application

First Name *

Last Name *

Phone *

Email *

Length of closure *
Up to and including (7) days - $75.00Up to and including (14) days - $125.00Up to and including (30) days - $225.00Up to and including (45) days - $300.00Each additional day after (45) days - $75.00 per day

Description of Work *

Start Date/Time *

End Date/Time *

Location of Work *

Side Streets *

Contractor Business Name

Contact First Name *

Contact Last Name *

Address

City

State
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

Phone *

Email

Attach a required Certificate of Liability Insurance for the street closure with permit application.

I, the above listed applicant, have thoroughly read and understand the conditions of this application. I understand that I must be present at the site and must be easily accessible at this project.
Applicant Signature: