TOWNSHIP OF MENDHAM

BOX 520 , BROOKSIDE , NJ 07926

Application for Road Opening Permit

Applicant's Name                                                                                                               

Name of Person or Firm doing work                                                                                 

Address                                                                              Phone No.                               

Location of Excavation (attach sketch or drawing)                                                         

Description of work to be done                                                                                          

For Service Connections or Curb Cuts:

Owner                                                                                                                               

Tax Map Block                                                                        Lot                                           

Starting Date                                                    Completion Date                      

Length of Excavation in feet                                              Width in feet                            

Square Yards of Pavement Affected                                                                                        

Name of Bonding Company                                                                                                     

Address                                                                                                                                  

Bond Expiration Date                                                                                                  

Name of Insurance Company                                                                                     

Address                                                                                                                  

Insurance Expiration Date                                                                                                        

Insurance Coverage:

Personal Injury-One person ($500,000. required)-Provided                             
Personal Injury-One occurrence ($1,000,000.required)-Provided                                
Property Damage- One accident ($500,000. required)- Provided                                
Property Damage- All accidents ($1,000,000.required)- Provided                           
Auto Libability- One person ($500,000.required)- Provided                            
Auto Liability- One occurrence ($1,000,000.required)- Provided                                 
Employer's Libability- Per occurrence ($500,000.required)-Provided                    
            Worker's Compensation as required by law.

Fees Required:

                                                                                   
Applicant                      Date

For Official Use Only:

Completion Date                                                                                                                     

Application Fee                                                                                         

Performance Guarantee                                                                                                           

Approved                                                                                         Date                            
                    Mendham Township Supt. of Public Works