Application For Curb Cut/driveway Permit Form printable pdf download

CITY OF FAIRFIELD, OHIO

APPLICATION FOR CURB CUT/DRIVEWAY PERMIT

Date ________________________________

Application is hereby made for a curb cut/driveway permit as follows:

Location: _________________________________________________________________________

Address

Lot No.

Type of Construction________________________________________________________________

Land Owner's Name ________________________________________________________________

Address ___________________________________ Phone Number ________________________

___________________________________ Zip Code _____________________________

Contractor's Name _________________________________________________________________

Address ___________________________________ Phone Number ________________________

___________________________________ Zip Code _____________________________

Work to be done ___________________________________________________________________

_________________________________________________________________________________

Date(s) work to be done _____________________________________________________________

POSITION OF CURB CUT/DRIVEWAY TO BE SHOWN ON A PLOT PLAN

Size of Curb Cut ___________________________________________________________________

Sidewalk/Curb Involved _____________________________________________________________

Present Use of Premises ____________________________________________________________

Distance to Intersection _____________________________________________________________

Size of Lot _______________________________________________________________________

Additional Driveway ________________________________________________________________

Drainage Structure Involved __________________________________________________________

APPLICANT’S SIGNATURE: ______________________________________________

PRINTED NAME:

_____________________________________________

ADDRESS:

______________________________________________

PHONE:

______________________________________________

Be sure to call the Construction Services Division at 867-8120 for an inspection.

Approved

Disapproved

Signature _________________________________________________________________________

Comments ________________________________________________________________________

cc:

Public Works Director

Utilities Director

Street Division

City Manager

City Engineer

Application For Curb Cut/driveway Permit Form