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2. Name
3. Email Address
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
12. Fax Number
14. Contractor's Name
15. Contractor's Phone Number
17. Contractor's Address
19. Type of Permit

    1. Utility
    2. Mailboxes
    3. Vegetation
20. Utility pole type
21. Utility box type
22. Anchor type
24. Distance from paved surface
26. Road
27. Sidewalk
28. Drive Approach
30. Mailbox - Type of Support

    1. Wood
    2. Steel Post
    3. Steel channel
32. Vegetation

    1. Planting
    2. Removal
    3. Trimming
33. If planting, specify type of vegetation
35. Plans Attached

    1. Yes
    2. No
36. Plans attached
37. Plans attached

39. I hereby agree to all terms, conditions and restrictions written or printed below and to the Right-of-Way Obstruction Regulations of Delhi Township, including the precautions for the protection of the public and all utilities within the public right-of-way and to any and all installation in and around said right-of-way.  If work done under this permit involves or endangers structures belonging to others, I shall immediately notify the owner.

    This permit may at any time be revoked or annulled by the Delhi Township Permit Department for non-performance and/or non-compliance with any of the conditions, restrictions, and or regulations.  Violations of or non-compliance of said regulations are subject to penalties provided by Sections 5589.10 and 5591.26 of the Ohio Revised Code.

    At all times during the progress of the work, adequate protection and passage shall be provided by the permit holder for the traveling public.

    Plans and/or applications must be approved and permit secured before commencing work.  Delhi Township regulations require that you notify the Delhi Township Permit Department in writing or call 513-922-8609 (between 7:00 AM and 9:00 AM) forty eight (48) hours before starting construction.  

41. Electronic Signature Agreement

    By checking the "I agree" 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 agree.
43. Electronic Signature
44. Date
    Date
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46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field