Obstruction of Public Way Permit Application

Applicant must obtain a permit at least two working days prior to the obstruction date. Application reviews may take up to 10 working days.
Application Date
Date Format: MM slash DD slash YYYY
Applicant Name
First Last
Applicant Address
Street Address Address Line 2 City State ZIP Code
Phone
Email
Obstruction Location
Start Date of Obstruction Requested
Date Format: MM slash DD slash YYYY
End Date of Obstruction Requested
Date Format: MM slash DD slash YYYY
Start Time

: HH

MM
End Time

: HH

MM
Location
Work to be performed or event
Check All That Apply
*Applicant must submit a traffic control plan - required for Village approval
- Street Closure*
- Traffic Lane Closure
- Sidewalk Closure
- Parking Lane Closure
- Driveway Affected
- Temporary Dumpster/Pod Placement
- Access to Business/Residence Affected
Other:
General Direction of Lane Closure
Side of Street Closure
In making application, the undersigned agrees to:
1. Provide a Cerfiticate of Liability Insurance indemnifying the Village of Mukwonago in the amount of $500,000 - $1,000,000 - $500,000 or a singe coverage of $1,000,000 per occurrence.
2. Provide reflective barricades on each end of the obstruction or substantial reflective tape.
3. Obey all Village of Mukwonago parking restrictions. The dumpster or pod may not be put in place until all of these items have been filed with the Public Works/Building Inspection Department.
Administrative Fee: $5.00
Signature