Permit #___________
State of: __________________________
County of: ________________________
Subscribed and sworn to before me, a notary public in and for said county and state, this _____ day of ________, 20____.
Notary Public ________________________
My commission expires ________________
Bond requirements for protection of street facilities:
______ $5,000.00 surety posted by contractor doing utility work
______ $500.00 surety posted by adjacent owner (homeowner)
______ public utility indemnification agreement posted
***Please make bond with the Delaware County Commissioner’s as the “Owners”
Office use only area
Inspection fees
______ Inspection fee for mailbox and driveway -- $20.00
______ Inspection fee for driveway only -- $20.00
______ Inspection fee for mailbox only -- $20.00
______ Inspection fee for special events -- $20.00
______ Review plans -- $20.00
______ Inspection fee $20.00 times number of days needed = $_________.
Street specifications
________ Class I _________ Class II _________ Class III ________ Class III subdivision
Office personel witness: __________________________________