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2. Application Date
   Application Date
3. Permit Number
5. Permit Information
   1. Permit Fee: $25.00
   2. Mandatory $1,000 bond to be submitted with Permit Application, and remain in force and effect 3 years from date of completion.
7. Applicant Information
9. First Name
10. Last Name
12. Address
14. City
15. State
16. Zip Code
18. Phone Number
19. Fax Number
21. Email Address
23. Alternate Contact Name
25. Location
    Provide detailed description of location at which work is to be performed.
27. Purpose of Work
    Examples: Install waterline, sanitary sewer, telephone, fiber optic cable.
28. Scope of Work
    Open cut, directional boring, in pavement, off pavement, etc.
30. Length
31. Width
32. Depth
34. Date Work is Anticipated to Commence
    Date Work is Anticipated to Commence
36. Date work is Anticipated to be Completed
    Date work is Anticipated to be Completed
47. Agreements
    Per Title V, Chapter 53, §53.02 of the Town of Zionsville Code of Ordinances, applicant acknowledges and agrees to the following, as evidenced by signature below.
49. 1. Any street cut, trench, access pit or other construction activity accomplished under this permit shall be restored per applicable specification(s) as set out in the Town of Zionsville Construction Standards. Restoration per applicable specification shall be accomplished within 5 working days of completion of the principal work activity for which the permit was issued. It shall be the permit holder’s responsibility to temporarily restore and maintain vehicle and/or pedestrian access and safety of any cut, trench, or access pit pending final restoration. Acceptance of temporary and final restorations, and ultimately, release of surety, shall be subject to approval by the Town of Zionsville. Restoration methods and materials are set out in the Town of Zionsville Construction Standards as follows:
    A. Asphalt Pavement – Specification Figures P-18, P-19, P-20
    B. Concrete Pavement – Specification Figures P-18, P-19, P-20
    C. Sidewalks / Pathways – Specification Figures P-18, P-21 Note: Approved flowable fill may be substituted for granular back fill.
51. 2. Any sod, plantings, or other landscaping materials or features disturbed as a consequence of the work under this permit shall be restored in kind. Acceptance shall be subject to approval by the Town of Zionsville.
53. 3. The permit holder shall be responsible to provide, erect, and maintain any necessary signs, barricades, lights, and / or other warning devices required to safely direct vehicular and pedestrian traffic over, around or through the work site, and to protect vehicles and pedestrians from any work site hazard. In the event a two-way, two-lane roadway is restricted to one lane, traffic control personnel may be required.
55. 4. The permit holder shall assume all responsibilities for any injuries or damages to persons or property resulting directly or indirectly from the work provided for under the permit.
57. 5. The permit holder shall notify the Zionsville Street Department prior to commencement, and upon completion, of the work provided for under the permit.
59. 6. A $1,000 bond posted in compliance with Chapter 7, Article V, Section 7-60 of the Town of Zionsville Code of Ordinances, shall not be released for a period of 3 years from the date of completion of the work and shall not be released without written acceptance of restoration by the Zionsville Street Department.
61. Signature of Applicant
62. Date
    Date
64. Permit Number
Leave This Blank:


68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit

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