TETON VILLAGE IMPROVEMENT & SERVICE DISTRICT P.O. Box 413 Teton Village, WY 83025 307-733-5457 office@tetonvillagewy.org CONSTRUCTION IMPACT PERMIT I have read the following sections of the Teton Village Improvement & Service District Rules & Regulations: Rule #2 Street Parking, Construction Impacting Streets, and Roadway Cuts, including #2.4 Construction Impact Permit and #2.8 Hearing of Contested Permit Breaches. I understand the terms stipulated and will agree to abide by them. Enclosed is the refundable deposit of $__________ (equal to 125% of the estimated surface reclamation cost - at minimum $20,000), made payable to the Teton Village Improvement & Service District. Please note that the estimate of repairs should be prepared by the property owner’s contractor / engineer and approved by the District. Property Owner _______________________________ Lot _________ Property Address ___________________________________________ Owner Mailing Address _____________________________________ Owner Phone ______________ Owner e-Mail ___________________ Owner Signature ___________________________________________ General Contractor Contact Info _______________________________ _________________________________________________________________________________
For completion by TVISD Check Name: Check Number: Date Received: