2. 

   
   

3. ROAD OCCUPANCY APPLICATION/PERMIT

5. SECTION 1 - APPLICANT INFORMATION

7. Applicant/Company Name*
9. Contact Person*
11. Address*
13. City*
14. State*
15. Zip Code*
17. Phone Number*
18. Fax Number
20. Email Address*

24. SECTION 2 - PROJECT INFORMATION  (Complete all that apply)

26. Work Location:  (provide address or from-to description)

28. Street Adress
30. From
31. To
33. Description of Work*

35. Work Schedule: 

37. Approximate Start Date:*
    Approximate Start Date:
38. Completion Date:*
    Completion Date:
40. Check all that apply*

    1. Street Opening (indicate length and width below)
    2. Shoulder Opening (indicate length and width below)
    3. Driveway Opening
    4. Outside of Shoulder Opening/Right of Way

    1. Residential
    2. Commercial
    3. Boring
    4. Sidewalk
42. Street Opening Length
43. Street Opening Width
45. Shoulder Opening Length
46. Shoulder Opening Width

50. For Borough Use Only

52. SECTION 3 - FEES

54. Permit Fees

56. $_________________  Driveway Opening:  Residential - $30.00 
                                                                            (if no building permit is issued)                            
                                                                        Commercial - $50.00
    $_________________ Street Opening:  Pavement Opening - $70.00 - Plus $2.00 per LF
                                                                              (LF = Linear Foot)
                                                                      Shoulder Opening - $50.00
                                                                      Outside of Shoulder Opening/Right of Way - $50.00

58. Inspection Fees

60. $_________________  Driveway Opening:  Residential - $20.00
                                                                        Commercial - $40.00
    $_________________  Street Opening:  Pavement Opening - $40.00
                                         Shoulder Opening - $25.00
                                         Outside of Shoulder Opening/Right of Way - $20.00 per hour

    
    

62. $_________________ TOTAL FEES

63. Date Fees Paid ______________________
67. Has performance guarantee been provided?*

    1. Yes
    2. No
68. Amount
69. Type

71. I acknowledge the aforementioned information and all General Provisions.

73. Accept this as my electronic signature.*

    1. Agree
74. Date*
    Date

76. Permit Approved:  ________________________________________________

77. Date:  _________________________

79. Final Inspection: __________________________________________________

80. Date:  _________________________

Leave This Blank:


82. 1. Receive an email copy of this form.
83. Email address

    This field is not part of the form submission.

84. Submit Submit and Print

* indicates a required field