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INDIAN RIVER COUNTY <br />RIGHT-OF-WAY REVIEW/PERMIT APPLICATION <br />DATE R.O.W. PERMIT NO. <br />APPLICANT <br />NAME PHONE <br />ADDRESS <br />CONTRACTOR <br />NAME EMERGENCY PHONE NO. (REQUIRED) <br />ADDRESS OFFICE PHONE NO. <br />LOCATION OF WORK <br />STREET ADDRESS <br />LOT BLOCK SUBDIVISION UNIT <br />DESCRIPTION OF WORK <br />TYPE OF REVIEW/PERMIT: (CIRCLE ONE) RESIDENTIAL COMMERCIAL <br />LAND DEVELOPMENT SITE PLAN <br />UTILITY <br />RIGHT-OF-WAY JURISDICTION: (CIRCLE ONE) PUBLIC PRIVATE <br />TYPE C STORMWATER REVIEW: (CIRCLE ONE) YES <br />NO <br />CONSTRUCTION TYPE: <br />DRIVEWAY" <br />CABLE TV <br />UNDERGROUND <br />STREET PAVING <br />ELECTRICITY <br />OVERHEAD <br />SIDEWALKS/CURBS <br />TELEPHONE <br />STORM DRAINAGE <br />RIGHT-OF-WAY <br />WATER SYSTEMS <br />CLEARING <br />SANITARY SEWER <br />OTHER <br />NOTE: 1. Detailed drawings shall be submitted with each application. <br />2. This permit is issued subject to all conditions on reverse side of this application. <br />3. A signature by the contractor shall be construed as making the contractor personally liable for all permit <br />conditions unless contractor attached written proof of authorization to act on behalf of the applicant. <br />4. All work is subject to final inspection by Engineering Division. Call 770-5455, "AIRS" (automated inspection <br />request system) to schedule inspections for any permit issued after January 1, 2003. <br />APPLICANT I CONTRACTOR SIGNATURE NAME (PLEASE PRINT) <br />OFFICE USE ONLY NOTES: <br />PERMIT FEE $ <br />ISSUING OFFICER <br />DATEISSUED <br />EXPIRATION DATE <br />Rev. 2/18/04 C:\Documents and Settings\webmaster\DesktoplROW APPLICATION FORM.doc <br />