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Right-of-Way & Excavation Permit City Utilities Close Out Form

  1. Who performed the work for this Permit?*

  2. Who is performing the repairs for this permit?*

  3. Fill out the following information only for items that are DIFFERENT than what is printed on the permit.

  4. Was a sidewalk cut?

  5. Was a sidewalk bored?

  6. Was a driveway cut?

  7. Was a driveway bored?

  8. Was a street cut?

  9. Was a street bored?

  10. Was ROW greenspace cut?

  11. Was ROW greenspace bored?

  12. Inspection

  13. Have trenches been repaired?*

  14. Has all sediment & debris been removed form project site?*

  15. Has project been properly backfilled with correct material?*

  16. Has disturbed area been replaced with seed or sod?*

  17. Have traffic control devices been removed?*

  18. Have erosion control devices been removed?*

  19. Have sidewalk, curb, driveways, or street been damaged?*

  20. If project exceeds permit expiration date, a renewal fee will be assesed at the cost of a new permit per the most current fee schedule.

  21. Failure to submit this form prior to the permit expiration date will generate a renewal fee at the cost of a new permit per the most current fee schedule.

  22. Typed name will be accepted as an electronic signature.

  23. By signing and submitting this form, Contractor and City Utilities notifies the City of Springfield that this project site is ready for inspection and approval. Submission of this form verifies that the Contractor has read and understands all parts of the form. By submitting this form, Contractor also ensures that the Contractor's work is complete and permit may be closed out. The City of Springfield will conduct final site investigation to determine if permit may be closed out. The Contractor is responsible for the work until they receive acceptance from the City of Springfield for the project. Submitting this form does not relieve the Contractor of responsibility for the work performed.

  24. Leave This Blank:

  25. This field is not part of the form submission.