Driveway and Private Sidewalk Restoration Reimbursement Application

Name of applicant

Email address

Street address

Primary phone number

Alternate phone number

What date was the construction completed adjacent to your driveway or private sidewalk?

Where did the work take place?

Sidewalk

Curb and gutter

Roadway

Other

Did the work cause, or increase the height difference between your driveway or private sidewalk and the City owned sidewalk/roadway to be at least 25mm (1 inch)?

Yes

No

Please indicate the length in which the height difference is more than 25 mm (1 inch):

Full length of driveway and/or private sidewalk

More than half of driveway and/or private sidewalk

Less than half of driveway and/or private sidewalk

I don't know

The information provided is accurate to the best of my knowledge on the date this application form was submitted.

I understand that, if I qualify for compensation, the compensation amount will be based on the approved fixed amount that was in effect at the time this application was received.

By submitting this application/form you acknowledge and agree that any electronic signature provided by you herein is the same as a handwritten signature for the purposes of legality, validity, enforceability, and admissibility.

I agree the the terms and conditions stated above

I agree

Please type your name below

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Clear

Date signed

I Want To...

Government

Recreation

Utilities

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Driveway and Private Sidewalk Restoration Reimbursement Application