2. 
4. Primary Company*
5. Supervisor*
7. Supervisor's Cell #*
8. Supervisor's Email*
10. Subcontractor
11. Subcontractor's Supervisor/Cell#
13. Subcontractor's Email
14. Start Date*
    Start Date
15. End Date*
    End Date
17. VDOT Certification
18. Work Location & Limits*
20. Purpose of Work*
22. Upload PDF/Files For Permit Application
    Please upload documents here
24. Obvious/Possible Conflicts With City Infrastructure
26. Asphalt To Be Removed (SQ.FT.)
27. Concrete To Be Removed (SQ.FT.)
28. Total Area To Be Disturbed (SQ.FT.)
32. Work To Be Performed
34. Utility Repair:

    1. Main
    2. Service
35. Utility Installation:

    1. Main
    2. Service
36. Dumpsters:

    1. Yes
    2. No
38. Tree Trimming:

    1. Yes
    2. No
39. Stump Grinding:

    1. Yes
    2. No
41. Other:
45. Equipment To Be Used
47. Track:*
    -- Select One --YesNo
48. Type/Number (if more than 1)
50. Rubber Tired:*
    -- Select One --YesNo
51. Type/Number (if more than 1)
53. Truck:*
    -- Select One --YesNo
54. Type/Number (if more than 1)
56. Boring Equipment:*
    -- Select One --YesNo
57. Type/Number (if more than 1)
59. Right-of-Way Permit Conditions
    Click Here

    Please read the conditions by clicking on the link.
63. Additional Comments
    Please Type Additional Comments Here.
65. I HAVE READ AND AGREE TO THE CONDITIONS OF THIS PERMIT AS STATED IN THE RIGHT OF WAY PERMIT CONDITIONS.
67. Date*
    Date

    Date
68. Signature*
70. City Staff Signature
    - _______________________________________________
Leave This Blank:


72. 1. Receive an email copy of this form.
73. Email address

    This field is not part of the form submission.

74. Submit

* indicates a required field