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2. 
3. DPW
   City of Taylor 23555 Goddard Taylor, MI 48180
4. This form is print only
   Please complete this form by signing in the respective field. Once signed please deliver or mail to the Department of Public Works at City Hall.
5. This permit is incomplete until a Permit Number is assigned. This application/permit should be accompanied by a site plan or engineering drawing for the described area.
7. Contact Information for Applicant
9. Name
10. Email Address
11. Phone Number
13. Address
15. City
16. State
17. Zip Code
21. Contact Information for Contractor
23. Name
24. Email Address
25. Phone Number
27. Address
29. City
30. State
31. Zip Code
35. Request: I do hereby make application for a permit to use the right-of-way of the following City street
37. City Street Name
38. Between Cross Streets
39. Section Number
40. County of
42. Nearest Major Cross Road
43. Distance to Nearest Cross Road
    (In feet)
44. Direction to Nearest Cross Road
    -- Select One --NorthEastSouthWest
45. Proposed Start/End Date
    Proposed Start/End Date Start Date

    —

    Proposed Start/End Date End Date
47. Purpose
    Describe work to be completed and location in detail
49. I certify that I accept the following*

    1. I accept

    Commencement of work set forth in the permit application constitutes acceptance of the permit as issued. Failure to object to the permit as issued within ten (10) days constitutes acceptance of the permit as issued. If this permit is accepted by either of the above methods, I will comply with the provisions of the permit. If this permit is for commercial or residential driveway work, I certify that I am the legal owner of the property for which this driveway will serve, or I am the owner's authorized agent.
51. Signature
    ________________________________________________
52. Date
    Date
56. City of Taylor Use Only
58. Comments/Concerns
59. Inspected By
61. Survey Type

    1. Cash
    2. Bond
    3. Credit Letter
    4. Exempt

    1. Resolution
    2. Self-Insured
    3. Retainer Letter
62. Liability Insurance

    1. Self-Insured
    2. Required
    3. Exempt
64. Reviewed By
65. Int
66. Date
67. Name/Title
Leave This Blank:


68. Print Only

* indicates a required field