Right of Way Permit

Location
Residential Driveway Approach Fee
per approach
Price: $60.00 Quantity:
Commercial Driveway Approach Fee
per approach
Price: $100.00 Quantity:
Survey Fee (New Construction)
per plot of survey
Price: $5.00 Quantity:
Curb Remove/Replace Fee
per linear foot
Price: $2.00 Quantity:
Monitoring Well Fee
per well
Price: $25.00 Quantity:
Sidewalk Fee
per square ($60 minimum)
Price: $25.00 Quantity:
Open Cut of Road Surface
per cut
Price: $100.00 Quantity:
Reason of Open Cut of Road Surface
Fee Total:
$0.00
Owner's Name
Name
Address
Street Address Address Line 2 City State ZIP Code
Phone
Owner Email*
Contractor's Name
Name
Address
Street Address Address Line 2 City State ZIP Code
Phone
Contractor Email
Insurance & Bond Information
Carrier
Name
Insured
Name
Limits - Each Occurrence
Each Occurrence
Medical Exp
Damage to Rented Premises
Personal & Adv Injury
General Aggregate
Products – Comp/Op Agg
The undersigned hereby agrees to perform the work according to the appropriate specification on file at Village Hall. The applicant also agrees to repair or replace any work that does not conform to said specifications and standards.
Owner or Agent Signature*
Date*
Date Format: MM slash DD slash YYYY

Insurance & Bond Information