2. CITY OF ELLISVILLE

   1 Weis Avenue

   Ellisville, Missouri 63011

   Phone: 636-227-9660  *  Fax: 636-227-9486

   
   

   RIGHT - OF - WAY  USE PERMIT

3. 
7. DATE ISSUED:
8. DATE EXPIRES:
9. PERMIT NUMBER:
11. THIS PERMIT INCLUDES APPROVAL FOR STREET CUTS? *

    1. Yes

    1. No
15. Project Location:*
17. Description of Work:*
19. Applicant Company Name:*
21. Address:*
23. City:*
24. State:*
25. Zip:*
27. General Contact:*
28. Contact Phone #:*
30. Email Address:*
32. Emergency Contact:*
33. 24-hr Emergency Phone #:*
35. Emergency Email Address:*
37. Work Performed For: (Company or Individual Name)*
39. Phone #:*
40. Email Address:*

42. Applicant affirmes he/she has read and will comply with Section 510.140, 510.50, 510.160 and 510.170 of the Ellisville Code.

    Applicant shall submit three (3) sets of sealed plans for permit requested work (electronic submissions in PDF format only).

    Applicant shall submit informational flyer for distribution to residents (if required).

44. Signature of Applicant:*
46. Date:*
    Date:

50. FOR OFFICE USE ONLY

52. Excavation Permit Fee @ $5.00:
54. Non-Refundable (510.130.A.4.a)
56. Inspection Fees @$55.00:
58. Non-Refundable (500.02.A.3)
60. Escrow Fee - Restoration $5.00 per Linear Ft of work:
62. Refundable (510.130.A.4.b)
64. Escrow - Street Cut - Street Cut $7.90 per sq. ft. of work:
66. Refundable (510.130.A.4.b)
69. Total Due: $

72. * Staff may review fees and may adjust the total amount assessed to reflect actual anticipated field conditions.

74. STATUS:

    1. APPROVED
    2. DENIED (513.130.B.5.X)
76. By:

80. REVIEWER

82. Plans Submitted:
84. Escrow Account Established: (510.150):
86. Hours of Work Noted: (510.140.G.5):
88. Street Closures (510.140.G.6):
90. Vegetation (510.140.G.14 & 510.170.C):
92. Information Flyer (510.140.H.6):
94. Street Cuts (510.140.H):
96. General Remarks:

98. Ver: 01/28/2020

Leave This Blank:


100. 1. Receive an email copy of this form.
101. Email address

     This field is not part of the form submission.

102. Submit

* indicates a required field