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City of La Porte <br />Phone: 281.470.5073 <br />Planning & Development Department <br />604 W. Fairmont Pkwy. <br />Fax: 281.470.5005 <br />La Porte, TX 77571 <br />www.laportetx.gov <br />PIPELINEPERMIT APPLICATION <br />1.PIPELINE PROJECT DATA: <br />JUD23#NfuibopmQspkfdu <br />Project Name: ______________________________________________________________________________________________________________________ <br /> <br />3:/733:68®O-1:6/16:541®X3:/8528:1®O-1:6/1:6245®X <br />Project Origin: _______________________________________________________ Project Destination: _____________________________________________ <br /> <br />23#Nfuibopm <br />Pipeline Diameter: ________________ Pipeline Commodity: ____________________________________________________________________________ <br /> <br />851831231efhsfftgbisfoifju <br />Normal Operating Pressure: ________________PSI; Max. Operation Pressure _________________PSI; Max. Allowable Temp. ___________________________ <br />2.PIPELINE OWNER: <br />JoufsdpoujofoubmUfsnjobmtDpnqbozMMD <br />Owner Name: ______________________________________________________________________________________________________________________ <br /> <br />Q/P/Cpy7:9-EffsQbsl-UY88647 <br />Owner Address: ____________________________________________________________________________________________________________________ <br /> <br />943.891.7843943.995.14:: <br />Owner Phone: ___________________________________________________________ Owner Fax: ________________________________________________ <br /> <br />tifjmAjufsn/dpn <br />Owner Email:_______________________________________________________________________________________________________________________ <br />3.PERMIT APPLICANT (Owner’s Agent): <br />Xppe/ <br />Company Name:____________________________________________________________________________________________________________________ <br /> <br />28436QbslSpx-Ipvtupo-UY88195 <br />Company Address:__________________________________________________________________________________________________________________ <br />UfsjQfsspoSjhiuPgXbzTqfdjbmjtu <br />Agent Name: ________________________________________________________ Agent Title: ____________________________________________________ <br /> <br />943/8::/:118 <br />Agent Phone: _______________________________________________________ Agent Fax: ______________________________________________________ <br /> <br />ufsj/qfsspoAxppeqmd/dpn <br />Agent Email:_______________________________________________________________________________________________________________________ <br />4.PIPELINE CONTRACTOR: <br />UCE <br />Company Name: ____________________________________________________________________________________________________________________ <br />Company Address: __________________________________________________________________________________________________________________ <br />Primary Contact Name: ________________________________________________ Primary Contact Title: ___________________________________________ <br />Primary Contact Phone 1: _________________________________________ Primary Contact Phone 2: _________________________________________ <br />Primary Contact E-Mail: _______________________________________________________________________________________________ <br />5.24-HOUR EMERGENCY CONTACTS: <br /> <br />UjnHvjeszQjqfmjofPqfsbujpotNbobhfs <br />Primary Contact Name:_________________________________________________ Primary Contact Title: ___________________________________________ <br />392.995.14:2943.576.1622 <br />Primary Contact Phone 1: ____________________________________________ Primary Contact Phone 2: ___________________________________________ <br /> <br />uhvjeszAjufsn/dpn <br />Primary Contact E-Mail: ______________________________________________________________________________________________________________ <br />TufwfoIfjm)evsjohdpotusvdujpopomz*QspkfduNbobhfs <br />Secondary Contact Name:____________________________________________ Secondary Contact Title: ____________________________________________ <br />943.891.7843457.344.7965 <br />Seconda ry Contact Phone 1: _________________________________________ Secondary Contact Phone 2: _________________________________________ <br />tifjmAjufsn/dpn <br />Secondary Contact E-Mail: ____________________________________________________________________________________________________________ <br />6.APPLICATION CHECKLIST & SUPPORTING DOCUMENTATION (Check applicable boxes): <br />COMPLETE ITEMS 1-6 OF PERMIT APPLICATION <br />SCHEDULED START DATE OF CONSTRUCTION: <br /> <br /> <br />SUBMIT PROJECT PLANS (3 HARDCOPIES –OR- DIGITAL .PDF) <br />Gfcsvbsz0Nbsdi-3133 <br />______________________________________________________ <br /> <br /> <br />ATTACH PIPELINE APPLICATION FEE OF $1,000.00 <br />ESTIMATE DURATION OF CONSTRUCTION: <br /> <br /> <br />PRINT & SIGN APPLICANT NAME BELOW <br />Bqqspyjnbufmz!7!npouit!gps!foujsf!qjqfmjof!opu!kvtu!qpsujpo!jo!Mb!Qpsuf <br />______________________________________________________ <br /> <br /> <br />Ejhjubmmz!tjhofe!cz!Qfsspo-!Ufsj! <br />EO;!do>Qfsspo-!Ufsj! <br />Qfsspo-!Ufsj <br />UfsjQfsspo <br />Ebuf;!3132/12/32!24;58;46!.17(11( <br />APPLICANT’S PRINTED NAME: ___________________________________________ APPLICANT’S SIGNATURE: ________________________________________ <br />32.3358.KME)22/13/3132* <br />(STAFF USE ONLY): PERMIT NO: ________________________________________ <br />PERMIT APPROVED BY: ___________________________________________ DATE OF APPROVAL: _________________________________ <br /> <br />