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2020-hop Gettysburg Borough

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U.S.A. forms for Borough of Gettysburg

BROWSE BOROUGH OF GETTYSBURG (PA) FORMS

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Revised Jan 2020 Page 1 Continued on Reverse
Gettysburg Borough
Application for Highway Occupancy Permit
For use with Ordinance No. 1397-12 amending Ch. 21, Part 1
regulating Streets and Street Excavations and Part 2 regulating
Sidewalks.
Applicant Information:
Application Date:
Name of Applicant:
Address:
Contact Person:
Email: __________________________________ Phone: __________________________
The applicant is a: Public Utility Property Owner Contractor
Site Information:
Site Address:
Opening Occurs between streets: and
Pennsylvania One-Call Serial Number:
Approx. Start Date: Approx. End Date:
Number of Trees in the Sidewalk:
Estimated Area of Sidewalk/Driveway (Total Square Feet): ________________________
Estimated Number of Street Openings: _________ Estimated Area of Street Openings (Total Square Yards.): _ ______
Estimated Linear Foot of Curbing: ________ Estimated Number of Days Street/Alley will be Closed: __________
Description of Work:
REQUIRED ITEMS THAT MUST BE SUBMITTED WITH APPLICATION FOR ADMINISTRATIVE COMPLETENESS:
Drawing or Sketch Submitted on an attached 8.5”x 11” sheet of paper. Drawing or Sketch must show Location
Map i
ncluding quantities of estimated street and/or sidewalk excavation.
Sketch all highway features (i.e., poles,
pipes, manholes, mains, laterals, bore pits, curb, sidewalk, location and size of openings, etc.). Include dimensions,
where applicable. Show North Arrow on sketch.
One Call Verified. Applicant shall submit a copy of the one-call form.
Visual Proof of present conditions (Photos or Video)
Proof of Insurance (for contractor)
ITEMS REQUIRED AFTER TECHNICAL REVIEW, BUT BEFORE THE PERMIT IS APPROVED:
Security Estimate (if applicable)
Security is Posted (if applicable)
Permit Fee is Paid
PERMIT TRACKING
Received by Borough
By:
Date:
Administratively Complete
By:
Date:
Technical Review
By:
Date:
Permit Approval
By:
Date:
Final Inspection
By:
Date:
Permit No:
Page 2
APPLICANT MUST CALL 2 BUSINESS DAYS IN ADVANCE TO SCHEDULE INSPECTIONS
(717)752-0570 OR (717)334-4666
The applicant agrees, by signing below, that the work shall be done in full compliance with the Ordinances of the Borough and
the laws of the Commonwealth in relation thereto, and that the applicant shall well and truly save, defend and keep harmless
the Borough from, and indemnify it against, any and all actions, suits, demands, payments, costs and charges for or by reason
of the proposed opening or excavation, and all damages to persons or property resulting in any manner there from, or
occurring in the prosecution of the work connected therewith, or from any other matter, cause, or thing relating thereto.
(Ord. 858-72, 5/15/1972, §4)
____________________________________ __________
Signature of Applicant or Authorized Representative Date
BOROUGH USE ONLY
Highway Occupancy Permit Fees:
STREET EXCAVATION
Item
Fee
Amount
Application Fee
$92.50
$
Min. Review Fee*
$100.00
$
Street Closing Fee
_____ days @ $250.00 per day
$
Degradation Fee
See Chart Below
$
Inspection Fee
$79.00
$
Curbing
_____ lin. feet @ $1.50/lin. ft.
$
Total:
$
SIDEWALK
Item
Amount
_____ sq. feet
@$25.00 per 50sq.ft.
$
Total:
$
DRIVEWAY
Item Fee
Amount
_____linear feet @ $1.00 per ft. in width
$
Total:
$
GRAND PERMIT TOTAL:
$
(Total of Street Excavation, Sidewalk, & Driveway)
Financial Security Amount $
*The applicant may be billed for any additional review that may be required by the Borough Engineer.
Degradation Fee Schedule:
1
st
Year 2
nd
Year 3
rd
Year 4
th
Year 5
th
Year 6
th
-10
th
Year 10
th
-15
th
Year Over 15 Years
$87/SY $77/SY $67/SY $57/SY $47/SY $37/SY $27/SY $17/SY
Activities with Approved Modifications/Waivers to the Ordinance Requirements:
If project falls under the requirements of Section 21-111-F requiring the complete width of the alley less than 14 feet to be paved, then
the degradation fee can be waived.
If the project is done outside of the paving season defined by the PennDOT 408 specifications for District 8-0 then the limit of 90 days
for temporary paving in Section 21-112-F can be modified.
Permit approved by
The Borough of Gettysburg this
_____ day of ______________, 20____
Borough Official Signature
- or -
Permit denied by
The Borough of Gettysburg this
day of , 20
Reason:
Borough Official Signature
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2020-hop Gettysburg Borough

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Completed 12 July 2020

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