VILLAGE OF HAZEL CREST
50/50 Public Sidewalk Replacement Application

NAME: __________________________________________ DATE:_____________________

ADDRESS: _______________________________________ PHONE: ___________________

Owner___________   Tenant___________    Improved____________     Vacant____________

Description of walk to be replaced:    WIDTH:     4   Ft._____    5 Ft.______                          

Present Condition:_____________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Number of squares to be replaced: ________________________________________________

Does a driveway cross the walk?   Yes_____    No_____

It is my understanding that this application for sidewalk replacement will be acted upon by
the Village in the priority of tripping hazard potential it attains after inspection by Village
Staff.  Only that sidewalk will be replaced which is deemed necessary by Village Staff.
Advance notice of actual work and costs will be given, and my share of all replacement
costs must be placed with the Village before the sidewalk is replaced. I AGREE TO
PERFORM THE NECESSARY LANDSCAPING REPAIRS AT MY OWN EXPENSE
FOLLOWING THE SIDEWALK REPLACEMENT.

___________________________________________   
   Signature                                                 

Date Received: ________________________________ Job Order No.:________________________________

Date Inspected:________________________________ By: ________________________________________

Present Condition (Grade, driveway, reason for replacement, etc.) ____________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

No. of squares to be replaced:_________________________________________________________________

Resident's Cost $______________________________  Notification Date: _____________________________

Date Paid:___________________________________  Work Begun: _________________________________

Received by:_________________________________   Completed:___________________________________

Last Revised: May 13, 2004 05:14 PM