L:\Permits\ROW\Construction Site-ROW Permit Application 2017
CITY OF HOOD RIVER
CONSTRUCTION SITE PERMIT/RIGHT OF WAY PERMIT
PLANS OR SKETCH MUST BE SUBMITTED WITH THIS APPLICATION
City of Hood River
1200 18
th
St (211 2
nd
Street), Hood River, Oregon 97031
Phone: 541-386-2383 Fax: 541-387-5222
PERMIT NO. 20 - ______
Applicant _________________________________ Map and Tax Lot Number ______________________________
Applicant Address ________________________________________________ Telephone _______________________
Applicant Email _______________________________________
Site Address______________________________________________________
Contractor _______________________________ Contractor Telephone __________________________
Proposed Work ____________________________________________________________________________________
Construction Start Date _________________ Completion Date ___________________
Applicant agrees to comply with all City of Hood River Engineering Standards requirements.
Applicant’s Signature __________________________________________ Date __________________
Other Permits applied for and status: (NPDES 1200 – C, County, State, attach additional pages if necessary)
Permit Fee: General: $94.00 _______ Street Cut: $170.00 _______ Receipt # ____________ Date: ____________
Engineers Cost Estimate Amount: $___________________ Review Fee is 2% of Engineer Cost Estimate
Plus Degradation Fee
Engineered Plan Review Fee: $__________ Receipt # __________ Date: __________
Is Contractor Pre-Qualified? Yes No
Date of Pre-Application Meeting: __________________ Date of Pre-Submittal Conference: __________________
Proof of Liability Insurance provided? Yes No - Proof of liability insurance is required for all work within
The Public Right of Way
Performance Guarantee provided? Yes No - Performance Guarantee is required for all Public
Improvements -110% of Engineers Cost Estimate
Warranty Guarantee provided? Yes No - A two year Warranty Guarantee is required for all public
improvements - 10% of Engineers Cost Estimate
Tree and Maintenance Bond Required? Yes No - A two year Warranty and Maintenance Bond is required
for trees - Amount Determined by City Engineer:
Street Opening Bond Required $ _________________ Receipt/Bond # ________________ Date _______________
Bond Provider: ________________________________ Address: ___________________________________________
Agreement in Lieu of Performance and/or Warranty Bond: Bank: ________________________ Date _______________
Degradation Fee: (if applicable) $ _________________ Receipt # ________________ Date _______________
Application is: *APPROVED - See Attached Conditions DENIED - See attached reasons for denial
ROW Permit only
_____________________________________________________ Date __________________
Stoner W. Bell, PE, City Engineer
A COPY OF APPROVED PERMIT WITH FINAL PLANS OR SKETCH MUST BE AVAILABLE AT JOBSITE
PERMIT IS VOID IF WORK HAS NOT STARTED WITHIN 30 DAYS
FOR INSPECTION CALL: 541-387-5201
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signature
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