To the City Engineer of the
City of Michigan City, Indiana

I hereby make application for a PERMIT to cut into*

at the following described location *

Street Number*

Lot No. and Block No.*

The type of street surface where the cut is to be made contains*

Nature of opening to be made:

The opening will be how long in feet*

by ________ feet wide*

______ sq. feet*

Please attach a sketch of the exact location, dimensions, depth of opening, etc, or attach blue print.*

Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)

Further Description*

Purpose of opening *

BRICK CONCRETE, BITUMINOUS CONCRETE, ASPHALT SURFACES
Minimum Charge- $50.00
Maximum Charge-$100.00

MACADAM SURFACE
Minimum Charge- $20.00
Maximum Charge- $100.00

SIDEWALK
Minimum Charge- $25.00
Maximum Charge- $100.00

Bond or bid security for $1,000 required *

Yes

No

Total Charges *