Request for Temporary Use / Closing of Roads / Parking / Sidewalks or Other Paved Area

Location (Describe and note on attached map):


Dates and Time of Usage Requested:


Extent of Usage (road width, no. of lanes, etc.):


Controls to be Provided (barricades, flagmen, etc.)


Requested By: __________________________ ______________
                                                 Project Officer                          Date

__________________________________________________________________

Approved By: _____________________________ _______________
                        Grounds Maintenance                                        Date
                        and Landscaping Section, ORF

          ___________________________ _______________
          Fire and Emergency Response                  Date
          Section (NIH Fire Dept.), DPS

         ___________________________ _______________
         Police Branch, DPS                                      Date

Comments or Conditions Imposed by Approving Officials:

________________________________________________________

________________________________________________________

________________________________________________________