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2. Permit Number (office use)
4. Date of Application*
   Date of Application
6. Address of Work*
8. City
9. State
10. Zip Code
12. Type of Work*
14. Name*
15. Email Address
17. Address
19. City
20. State
21. Zip Code
23. Phone Number*
24. Fax Number
26. Bonded Contractor/Company Name*
28. Bond for Right of Way Work
    The City requires the contractor to have a bond through the City to do work in the Right of Way. Please contact Hanane at 937-237-5811 for questions about this.
30. Fee Schedule
    Engineering Fee Schedule
31. Payment

    After you submit this form, you will be automatically redirected to the online payments page.

33. Please Read the Below Agreement Before Submitting
    Rules & Regulations for working in the Right of Way
34. Signage Required

    *Signage is required if a steel plate has been placed on the road. 

36. Electronic Signature Agreement*

    By checking the "I acknowledge" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I acknowledge
38. Electronic Signature
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field