PERMIT # ______________

CONTRACTOR/APPLICANT*

ADDRESS*

PHONE #*

EMAIL*

FOR A PERMIT COVERING WORK AS SPECIFIED BELOW FOR:

OWNER OR AGENT*

LOCATION*

BLACK JACK, MO 63033

PURPOSE/DESCRIPTION OF EXCAVATION*

START DATE*

COMPLETION DATE*

TYPE OF PAVEMENT*

CONCRETE ASPHALT

GRASSY AREA

TYPE OF BACKFILL*

LENGTH*

WIDTH*

DEPTH*

OF DITCH

SPECIAL CONDITIONS

I AGREE TO DO ALL THE ABOVE WORK IN STRICT ACCORDANCE WITH ABOVE STATED PROVISIONS AND WITH CITY ORDINANCE NO. 79

EMAIL ALL SUPPORTING DOCUMENTS TO DEPUTYCOURTCLERK@CITYOFBLACKJACK.COM

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FOR OFFICE USE ONLY DO NOT WRITE BELOW THIS AREA

LIABILITY INSURANCE $_______________

DATE APPROVED _________________________

CASH DEPOSIT $_______________

APPROVED BY _________________________

PERMIT FEE $_______________

ISSUED BY _________________________

PAYMENT TYPE: CREDIT CARD/WEB__________ CASH__________ MONEY ORDER/CASHIER CH __________ RECEIPT #__________