APPLICATION TO USE THE PUBLIC RIGHT OF WAY
LEGAL NAME OF ENTITY:
APPLICANT INFORMATION
PERMIT MAILING ADDRESS:
CITY<y& STATE ^' ZIP CODE: 4>&&fV
-fa CONTACT PERSON; fioJje, Cj&nTT&l
"Dinsc-br, Concept t>ye.l op r title T^esiflh * ^forc Phwyna foV
EMAIL:
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epartment of Btutncn
Oalra nd Coumicr Prsttclltn
uMh Way Utt Vail
uitomcr Service Center
13 & Salt Street, Suite LUO
hlafo,lL60«M-39T7
HJ)74-COBIZ (7444249) 17.)74J-I»74(TTY)
^phoneI^)^8^7eaxT 4.__________
USE OF THE PUBLIC WAY
I. List the proposed or existing use below add complete the attached worksheet Only use one application per public way use type.
Type
* A
How many?
___idlne Address
2. Please enclose one sketch of proposed use of the public way, which maps to scale
the proposed use and its relationship to surrounding right-tftevay. All measurements must be
indicated.
The prints should also accurately depict the location or the property line and public facilities (meters, light poles, sidewalks).
APPLICANT CERTIFICATION:
I herebv certify t at all statements made as part of (he application and Ihe attachments hegretn. and rfte' o the best of knowledge and belief.
-35^ F.E.I.N. or Soahl Security Number:
**Q0-W6G<W .
As part of (his application process, you are required to notify/obtain approval from the Alderman in whose ward your proposed use of the public way is located.
vLDERMAN-S sign,
HI
DATE