2. Encroachment Permit Number*
4. Permittee/Contractor Name*
6. Permittee/Contractor Email Address*
8. Upload Insurance Certificate*

   View the insurance requirements here.
   For a sample of an insurance certificate, go here.

10. Submitter Name*
12. Submitter Email*
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14. 1. Receive an email copy of this form.
15. Email address

    This field is not part of the form submission.

16. Submit

* indicates a required field