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O <br />br9ghb­ <br />hiffiwiiim <br />E-Z <br />INDIAN RIVER COUNTY <br />RIGHT-OF-WAY REVIEW/PERMIT APPLICATION <br />R.O.W. PERMIT NO. <br />NAML <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 NO <br />CONSTRUCTION TYPE. <br />DRIVEWAY* CABLE TV UNDERGROUND <br />STREET PAVING ELECTRICITY OVERHEAD <br />SIDEWALKS/CURBS TELEPHONE STORM DRAINAGE <br />RIGHT-OF-WAY WATER SYSTEMS CLEARING <br />SANITARY SEWER 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 77D-5455, "AIRS' (automated inspection <br />request system) to schedule inspections for any permit issued after January 1, 2001 <br />APPLICANT I CONTRACTOR SIGNATURE NAME (PLEASE PRINT) <br />OFFICE USE ONLY NOTES: <br />PERMIT FEE S <br />ISSUING OFFICER <br />DATEISSUED <br />EXPIRATION DATE <br />Rev. 2/la/04 C:0—iments and Settings\vebmaster\Deslaop\ROW APPLICATION FORM.dm <br />