1. Location of fence or wall (attach site plan: __________

___________________________________________________

___________________________________________________

2. Fence or wall description/type of construction (attach fence or wall design/construction detail): _____________

___________________________________________________

___________________________________________________

___________________________________________________

3. Property Owner:

Name: ___________________________________________________
                                          (Please Print)
     
Address: ___________________________________________________
                                                                           
                    ___________________________________________________

Phone (H) _____________________     (W) ____________    

Fax: _________________    Email: _____________________

It is understood and agreed that any certificate issued pursuant to this application is issued on the condition that the information provided herein is accurate to the best of the knowledge and information of the applicant. This applicant acknowledges to have read and understood the application instructions attached hereto.

I agree to restore to original condition any facilities on public right-of-way damaged by installation of the wall/fence, including, but not limited to, landscaping, sidewalk, trees and drainage.

Signed: ______________________________     Date: _____
                              Applicant

Applicant: ____________________________________________________
                                              (Please Print)

Contractor: ________________________________________

Address: ___________________________________________

Telephone: ___________________    Fax: ______________