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City of Bloomfield - AWS
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City of Bloomfield
Street Excavation Permit Date: _________________________________________ Applicant’s name: _____________________________________________________________ Mailing address: ______________________________________________________________ Physical address: _____________________________________________________________ Phone number: _______________________ Mobile number: _________________________ Fax number: __________________________ E-mail: _______________________________ Project location (street address): _________________________________________________ Type of street: Paved _________ Unpaved ________ Purpose of excavation: _________________________________________________________ Dimension of excavation: _______________________________________________________ Contractor: _____________________________________ License # ____________________ Proof of liability insurance: _____________________________Expiration:______________ Deposit: Cash: ____ Bond: ____ (copy of bond must be attached to application). Applicant signature: _____________________________________ Date: ________________ Inspection / Admin. Fee of $25.00(non-refundable) plus deposit. Permit deposit paid - Amount: $ ____________ Cash: ___ Check #: ___________________ Permit - approved ___denied ___ by: _________________________Date: ______________ (City of Bloomfield) Final inspection by: ___________________Approved: ___ Rejected ___ Date: __________ (City of Bloomfield) Comments: __________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
915 N. First
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P.O. Box 1839
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Bloomfield, NM 87413
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Fax: (505) 632-8055
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Off.: (505) 632-8448
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