Waiver Request Form
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Company Name
Company Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Company Email
example@example.com
Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Person
First Name
Last Name
Project Information
Project Name
Project Description
Scope of Work
Project Type
Road repair
Sealing and patching
Road reconstruction
Resurfacing of the road
Road maintenance
Sidewalk lane repair
Temporary structures
Electrical and vault repairs
Other
Start End
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Estimate End Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for waiver request
Attach a document of any related approval documents for the construction
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Attach a copy of the floor plan or any documents that shows the work plan
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Attach any related images or photos that is related to the waiver that will assist in evaluating the request
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Agreement
I confirmed that all information in this form is accurate and true to the best of my knowledge.
I understand that the appropriate department or authority has the right to conduct an onsite inspection.
I understand that I am required to notify the appropriate department or authority for changes on this permit.
Person assigned on the project (admin)
First Name
Last Name
Signature of the Person assigned on the project
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Authorized Person Only
Â
Request Status
Approved
Denied
Comments
Approver's Name
First Name
Last Name
Approver's Signature
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: