Shipshewana Form

Application to Work on Town Right-of-Way
Instructions:

1.      For driveway work, instead submit the Town Driveway Construction Permit Application.

2.      The applicant (“Applicant”) must fill this form completely. Any inapplicable box must be marked “N/A.”

3.      Applicant shall submit required plans and specifications and proof of insurance.

4.      Applicant shall submit proof of Contractor’s work qualifications (for example, a copy of pages 1-4 of the Contractor’s State Form 96) and permit bond.

5.      Enclose application fee of $100.00 ($75.00 if no cuts/bores), payable to Town of Shipshewana.

6.      By signing below, Applicant agrees to be bound by all the enclosed Terms and Conditions.

7.      Contact the Town of Shipshewana Street Department for questions concerning this application.
Permit# :
Street Department

345 N Morton St.; P.O. Box 486

Shipshewana, IN 46565

Phone: (260) 768-4743

Fax: (260) 768-4608
Applicant's Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Primary Phone Number *

Area Code Phone Number
Alternate Phone Number *

Area Code Phone Number
Email *
example@example.com
Project Owner's Name if Different
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Project Location and Proposed Timeline *
Project Purpose and Details of the Project *
Application Date *

Month Day Year
Signature *

Clear
Upload Documents *

Browse Files

Cancel of

My Products

product

Application Fee (No Cuts/Bores) $ 75.00

Application Fee (No Cuts/Bores)

product

Application Fee (With Cuts/Bores) $ 100.00

Application Fee (With Cuts/Bores)

Total $ 0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Do not write in this section below
Administrator:
Date

Month Day Year
Should be Empty:

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