Form Center

2. 
4. EASEMENT ENCROACHMENT APPLICATION
6. Project street address:*
8. Parcel number (no dashes):
9. City lot # (if applicable):
11. Subdivision (if applicable):
13. Proposed structure/description of work:*
15. Please attach a plan with the proposed structure drawn in. For this plan, you can use a lot improvement plan from when the house was originally built, a current lot survey, or an aerial view obtained from Medina County GIS (Tax Maps). Include location of proposed structure, north arrow, street labels, existing buildings and property lines.
17. File upload #1
21. PARCEL OWNER INFORMATION
23. Name:
25. Mailing address:
27. City
28. State
29. Zip Code
31. Phone:
32. Email:
34. CONTRACTOR/AGENT (if applicable)
36. Contact name:
37. Company:
39. Mailing address:
41. City:
42. State:
43. Zip code:
45. Phone:
46. Email:
50. Damage to underground utilities resulting from this excavation shall be the responsibility of the contractor performing the excavation. Before starting any excavation the Contractor MUST contact the Ohio Utilities Protection Service (OUPS) at 8-1-1 or 1-800-362-2764, at least 48 hours but no more than 10 working days before beginning ANY digging project.
52. For Engineering Department permits:
54. 1. Failure to obtain inspections may result in penalties and/or removal and reconstruction of improvements.
56. 2. Required inspections can be arranged by calling (330) 335-2751 or by visiting the Engineering web page at https://www.wadsworthcity.com/FormCenter/Engineering-10/INSPECTION-SCHEDULING-67. Inspection must be requested by 2:00 p.m. one business day before the inspection is needed.
60. Applicant's statement:
62. 1. I hereby certify that the owner of record authorizes the proposed work and this application, and I am acting as the agent on their behalf.
64. 2. I agree to conform to all applicable laws of the City of Wadsworth, all applicable codes and provisions stated in this application.
66. 3. I hereby certify that all land clearing, construction or development involving the movement of earth shall be in conformance with standard erosion, runoff and sediment control practices to prevent soils from being deposited onto adjacent properties, rights-of-way, public storm drainage systems, wetlands and/or watercourses.
68. 4. I agree to obtain the required inspections.
70. 5. I agree that authorized inspectors shall have the authority to enter areas covered by such permit, at any reasonable hour, to enforce the provisions of the code.
72. 6. I agree to comply with the above conditions, specifications and regulations of the City of Wadsworth governing this application. I understand that failure to comply may be cause for revocation of this application and issuance of a stop work order.
74. Digital signature of applicant:*
75. Date:*
    Date:
Leave This Blank:


77. 1. Receive an email copy of this form.
78. Email address

    This field is not part of the form submission.

79. Submit Submit and Print

* indicates a required field