BPP-5 (Rev. 12/14)

BUILDERS PAVEMENT PLAN

AUTHORIZATION TO THE DEPARTMENT OF TRANSPORTATION To Issue Construction Permit for the Builders Pavement Plan Work

BPP # BIS # Permit #

Project Lead Address: BK BX MN QNS SI

Block Lot Owner’s Name: Telephone Number: E-mail Address:

Street Number 1: ______________________________________________________________ Between (Provide cross streets) __________________________and ______________________ New Curb___________________ Linear Feet ___________

New Concrete Walk___________ Linear Feet ___________

New Roadway Pavement*__________ Linear Feet ___________by _____ Feet wide

Street Number 2: ______________________________________________________________ Between (Provide cross streets) __________________________and ______________________ New Curb___________________ Linear Feet ___________

New Concrete Walk___________ Linear Feet ___________

New Roadway Pavement*__________ Linear Feet ___________by _____ Feet wide

Street Number 3: ______________________________________________________________ Between (Provide cross streets)___________________________and ______________________

New Curb___________________ Linear Feet ___________

New Concrete Walk __________ Linear Feet ___________

New Roadway Pavement* __________ Linear Feet ___________ by ____ Feet wide

* Department of Transportation permits include an asphaltic repair strip in the roadway next to the new

curb.

______________________________________________ Date__________

Professionals Signature *

______________________________________________ Date__________

Department of Buildings Representative

*A registered architect, registered landscape architect or licensed engineer is required to submit form.