Encroachment Permit Application Form Florence, Kentucky

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Encroachment Permit Application
Applicant
Contact Person: _______________________________
Company: ___________________________________
Address: _________________________________
City: _________________
State: ____
Zip: __________________
Office Phone: (_____) ______-______
Cell Phone: (_____) ______-______
Fax: (_____) ______-______
Email: ____________________________________ Occupational License Number (if applicable): ______________________
(Must have valid/current occupational license if being compensated)
Property Owner
Name: ____________________________
Address: __________________________________
City: _________________
State: ____
Zip: _________________
Office Phone: (_____) ______-______
Cell Phone: (_____) ______-______
Fax: (_____) ______-______
Email: ____________________________________
Project Location
Address: __________________________________
City: _________________
State: ____
Zip: _________________
Location on Property: ____________________________________________________________________________________
______________________________________________________________________________________________________
Type of Encroachment
(Check all that apply)
Encroachment Description:
Entrance/Curb Cut
Residential
_______________________________________________________
Commercial/Business
_______________________________________________________
Utility
_______________________________________________________
New Overhead
_______________________________________________________
New Underground
_______________________________________________________
Repair/Maintenance
_______________________________________________________
Building/Grade Work
_______________________________________________________
Fill
_______________________________________________________
Landscape on Right of Way/Easement
_______________________________________________________
Structure in Right of Way/Easement
_______________________________________________________
Other ______________________
_______________________________________________________
Pavement Cut
Street
*****NOTE*****
Sidewalk
Please attach a descriptive drawing that shows the encroachment and its
Driveway
relation to any nearby existing utilities and/or structures. Application will not
be approved without a drawing.
Other ______________________
Proposed Start Date: _________________
Proposed Completion Date: ___________________
Restoration Plan Attached
Traffic Control Plan Attached
(I/We) hereby certify that all the information contained in this application is true and complete to the best of my knowledge and (I/We) will
comply with the terms and conditions under which the encroachment permit hereby applied for is issued. Furthermore, (I/We) agree to
fully indemnify and hold harmless the City and all of its employees, officials and representatives from any claim, damage or injury to a
person or property arising or alleged to arise from any work related to the approved encroachment or work thereof.
Applicant Signature: __________________________________
Date: __________________________
Property Owner Signature: ____________________________
Date: __________________________
Permit is hereby granted to perform such work. A copy of the permit, the application and the specification shall be available at the jobsite
at all times.
Permit Approved By: ________________________________
Date: __________________________
Final Inspection Approved By: _________________________
Date: __________________________
(Office Use Only) Requires Inspection 
Requires Bond/Insurance 
Requires Additional Plans (Traffic Control or Restoration) 
Record/GBA Number: ________________
Public Services Department
8100 Ewing Boulevard  Florence, Kentucky 41042-7588  (859) 647-5416  Fax: (859) 647-5438

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