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2. Date of Request*
   Date of Request
4. Franchisee Name:*
6. Right-of-Way User Applicant

   Please provide contact information for person completing the form.

8. Company Name:
10. First Name*
11. Last Name*
13. Address1*
14. Address2
16. City*
17. State*
18. Zip*
20. Phone:*
21. Fax:
23. Email Address*
27. Right-of-Way User/Franchisee Contact

    Must be available 24 hours. All fields below must be completed even if information is the same or application will be rejected. 

29. First Name*
30. Last Name*
32. Title:
34. Office Phone:*
35. Mobile:*
37. E-mail Address:*
41. Sub-Contractor Performing Work

    All fields below must be completed even if information is the same or application will be rejected. 

43. Company Name:
45. First Name*
46. Last Name*
48. Address1*
49. Address2
51. City*
52. State*
53. Zip*
55. General Contractor Phone:*
59. Sub-Contractor Primary Contact

    Must be available 24 hours.   This must be the supervisor on job site.

61. Company Name:
63. First Name*
64. Last Name*
66. Title:
68. Office Phone:*
69. Mobile:*
71. E-mail Address*
75. Location of Desired Work
77. Address of Location & List Route from Where to Where:*
79. Proposed Start Date:*
    Proposed Start Date:
80. Proposed Completion Date:*
    Proposed Completion Date:
82. Linear Feet of Job:*
84. Traffic Control Plan (Required)*
86. Plan Set (Required)*
88. Attach Location Map/Drawing*
90. I certify that to the best of my knowledge the information porvided in this permit application is accurate.*

    1. Yes
92. Damages existing at location prior to start of project:
94. Please describe any damage existing prior to work beginning. Any and all damages must be reported here or contractor will be held accountable for the condition in which the job site is left.
96. Terms and Conditions:
98. If contractor is suspected of damaging water and/or sewer lines while working on site, contractor will be responsible to for running a camera down the lines at the contractor's cost. Contractor must adhere to the City of Midlothian storm water requirements. Contractor needs to notify homeowner prior to working on private easement. Properties must be left in better condition than originally found which includes cleaning worksite and replacing sod if applicable. *

    1. I agree to the Terms and Conditions
102. Office Use Only
104. Approved ___________ Denied____________
106. Terry Williams, Public Works Operations Manager______________________________
108. David Ford, Streets Foreman________________________________________________
110. Thurman Ross, Utility Superintendent________________________________________
112. Reason for being denied (if applicable) or notes pertaining to approval:
Leave This Blank:


116. 1. Receive an email copy of this form.
117. Email address

     This field is not part of the form submission.

118. Submit Submit and Print

* indicates a required field