Fillable 639 Permit for Excavation of Construction Within a Public way or Public Easement

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639 Permit for Excavation of Construction Within a Public way or Public Easement

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2/01/2020
1
Date:_______________
CITY OF CODY Time: _____________
ENCROACHMENT PERMIT APPLICATION
Eligibility Requirements:
No person will be eligible to receive a permit to work in any public right-of-way unless said person is an employee of an
approved utility operating under a franchise agreement with the City of Cody or said person has provided proof of
$500,000 commercial general liability insurance and has a license and or permit bond bound unto the City of Cody in the
amount of $25,000.00.
Insurance Company ______________________________ Policy Expiration Date: ________________
(Attach copy of proof of insurance)
Permit Fee: $50.00 Deposit: $150.00
This permit is issued to: (hereinafter referred to as “Permittee”)
Name: __________________________________________________ Phone #______________________________
Address: ____________________________________________________ Fax # _______________________________
____________________________________________________ Email _______________________________
Permittee with the Approval of the Director of Public Works or his/her designee requests this permit for the
purpose of: (Check appropriate items):
STORAGE - place, store, brick, timber, lumber on or upon a public way ($150 deposit required)
OBSTRUCTION - Completely obstruct a public way for a continuous period of time.
EXCAVATION - Excavate a public way or public easement within the City of Cody.
(Street)___________________________________
(Alley)___________________________________
(Other)__________________________________
Start Date of Project: ______________ Completion Date of Project: __________________
(Permitte must notify the Streets Division at 587-2958 with any changes to the Beginning or Ending Dates.)
Address of Project: _____________________________________________________
Purpose of Project: _____________________________________________________
Estimated Depth of Excavation or Bore:_________________________________________________
Description of Excavation: ____________________________________________________________________
Excavation Contractor: _____________________________________________________
**Paving Contractor: _____________________________________________________
** If the City of Cody is to pave the area, Permittee will be charged for all costs associated with the repair. The City of Cody may elect to use a private
contractor for the repairs.)
Encroachment Permit is valid for 45 days from date of permit and is non-refundable
Taken By: ________ Insurance Verified By: ________ Streets Dept Notified By: _______ Approved Y N
Deposit Paid: Check_____ Cash ______ Credit Card ______ Permit Fee: Paid _________ Invoiced_________
2/01/2020
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CITY OF CODY
Please Identify Dig Area
INDICATE NORTH
(A) (B) (C)
*All agencies, and companies working within the right-of-way shall use the latest version of the MUTCD (Manual on Uniform Traffic
Control Devices). The safety of you, your employees and the public depends on the correct use of traffic control.
Please Indicate Traffic Control Plan:
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Permittee and City acknowledge and agree that the resurfacing work described above shall be begun and carried
through to conclusion as soon as is reasonably possible following the conclusion of the excavation itself and whatever
subsurface work necessitated the excavation. Resurfacing work, to the satisfaction of the Director of Public Works or
his/her designee, shall be completed on or before the completion date stated above provided, however, that upon good
cause shown, the Director of Public Works or his/her designee, may extend the period of time for performance under
the terms of this contract. (Typically 10 working days).
The Permittee is responsible for contacting “Wyoming One-Call” at (800) 849-2476 before doing any excavation.
Damages to underground utilities are covered by Wyoming Statutes 37-12-301 through 37-12-304.
If any public way will be completely obstructed for a period of more than two (2) hours, the Permittee shall notify the
Police Department, Fire Department, Hospital, and the local news media of the type of obstruction, the length of time
and the public way to be obstructed. (Attached, Street Closure Notification Form)
If any public utility will be out of service for more than five (5) minutes, the Permittee shall notify the appropriate
persons or agencies that will be affected.
Any person having an encroachment permit for any public way or public easement in the City shall, at a minimum,
provide a fence or a barrier around said excavation and shall display a lighted sign at said excavation during the hours
of darkness. All barricading and signing shall be done in accordance with the Manual of Uniform Traffic Control
Devices (MUTCD) and the Wyoming Supplement to the MUTCD. Permittee must submit a traffic control plan with
this encroachment permit application.
If repairs cannot be made due to inclement weather conditions, the Permittee shall maintain barricades or the surface
of the excavation at his own expense until the complete repair can be made properly. In the case of winter street
excavations, cold mix asphalt will be placed in the excavation as often as necessary to maintain a smooth travel
surface.
Upon completion and prior to City approval of any permitted work where utility services were provided, the Permittee
shall provide a sketch showing the location of the new services in relation to property corners or in relation to existing
manholes, fire hydrants or water valves.
Permittee agrees to provide the City with a two-year warranty of compliance with all relevant City specifications for
that area they have resurfaced. This warranty shall begin as of the date that the street was installed or repaired and has
been approved by the City.
Permittee agrees to pay the City of Cody $750.00 plus the actual costs (time and material) incurred to make the
necessary repairs if Permittee fails to do so.
* NOTE:
** The Director of Public Works or his/her designee shall at all times have the right to inspect the work and materials.
The Director of Public Works or his/her designee shall make such inspections, as he may deem necessary. The Contractor
when necessary shall furnish excavation equipment and an operator for excavation of materials for inspection purposes.
** All work shall be in conformance with the City of Cody street construction standard details, which may be obtained at
the City engineer’s office.
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Conditions and Construction Requirements
Conditions.
The following conditions are in effect regarding the issuance of encroachment permits. If any Permittee is found to be out
of conformance with one or more of these conditions, the City will issue a stop work order. The stop work order will
remain in effect until the conditions are in conformance.
Eligibility Requirements:
No person will be eligible to receive a permit to work in any public right- of -way unless said person is an employee of an
approved utility operating under a franchise agreement with the City of Cody or said person has provided proof of
$500,000 commercial general liability insurance and has a license and or permit bond bound unto the City of Cody in the
amount of $25,000.00
Permit Fee:
1. The standard fee for encroachment permit required herein is thirty dollars ($30.00).
Special Deposit:
2. a) A Special Deposit will be required from persons who apply for permits for obstructing
public ways and for permits for placing stone, timber, etc., on a public way. The Special
Deposit will be required at the time of application for their permit and the fee for the Special
Deposit will be determined as follows:
I. The Special Deposit fee on permits for Obstructing Public Ways and permits for Placing Stone,
Timber, etc. on Public Ways shall be a standard $150.00.
b) Upon completion of the work and after the Director of Public Works or his/her designee has inspected and
approved the work, the Special Deposit will be returned to the Permittee. However, if the Permittee fails to
complete the required work within the allowed time or if the work is not done in accordance with City
Specifications, the City will draft the Permittee’s entire Special Deposit to complete the work.
3. The Permittee cannot transfer or assign the permit to any other person.
4. Encroachment permits will not be issued for a period of two (2) years on streets that have been newly paved,
repaved or reconstructed. The only exception is in the case of an emergency declared by the Director of Public
Works or his/her designee. When additional underground service utilities are needed on a new street, the
Permittee will be required to tunnel or bore the new street in order to provide said services.
Construction. General.
(a) All construction will be performed in accordance with the City of Cody Construction Specifications and Design
Standards.
Traffic Control, Signage, and Safety Apparel.
The Permittee is required to maintain traffic control and provide adequate signing, per the latest version of the MUTCD,
for vehicle and pedestrian traffic until the permit work is completed.
City of Cody policy and federal regulations require the use of high-visibility safety apparel for all people within the right-
of-way. Failure to wear appropriate high visibility safety apparel may result in forfeiture of this permit or charges as
noted. All workers within the right-of-way who are exposed either to traffic (vehicles using the highway for purposes of
travel) or to work vehicles and construction equipment within the TTC (Temporary Traffic Control) zone shall wear high-
2/01/2020
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visibility safety apparel that meets the Performance Class 2 or 3 requirements of the ANSI/ISEA 107–2004 publication
entitled “American National Standard for High-Visibility Safety Apparel and Headwear” (see Section 1A.11), or
equivalent revisions, and labeled as meeting the ANSI 107-2004 standard performance for Class 2 or 3 risk exposure.
** Failure to provide and maintain adequate traffic control, and/or safety apparel will result in forfeiture of permit,
and if deemed necessary the City of Cody will make the area safe and Permittee will be subject to a $300 charge, plus
the actual costs associated with the action to make the area safe including the possible rental fee of proper signage.
Trench Detail.
Unless otherwise ordered by the Director of Public Works or his/her designee, typical trench detail specifics shall be
as follows:
A. All Paved City of Cody Streets.
1. The finish course of all paved streets will be cut out to a 5 foot minimum width, to be reviewed on
the site by the Director of Public Works or his/her designee and laid to a compacted depth one inch
deeper than the pavement being replaced, but not in any event less than three inches, with appropriate
paving equipment and utilizing a pavement machine in all instances in which pavement is required to
be placed for trenches or other excavations of any kind next to curb and gutter projects, except that, in
the case of small holes and short, narrow trenches, the Director of Public Works or his/her designee
may approve other procedures which, in his judgment, are sufficient to meet standards for compaction
and other specifications and requirements applying to street construction.
2. The asphalt to be used shall be ½” inch hot mix asphalt, as determined by the Director of Public
Works or his/her designee, compacted and contiguous with existing asphalt road.
B. Type A trenches 24” in depth and shallower
Trench must be filled from bottom to within 3” of finish grade with sand slurry containing:
Cement (0.45 sack/CY)
Water (39 Gallons/CY)
Coarse Aggregate (Size No. 57: 1700#/CY)
Sand (ASTM C-33; 1845 #/CY)
Type A trenches are exempt from compaction tests, leveling course and road base requirements. Sand
slurry, without the cement additive, if approved by the city is also an acceptable alternative.
Trenches 24”in depth and greater:
Materials used for bedding and backfill shall be carefully deposited in layers suitable to the
equipment used for compaction, wetted to optimum moisture content and compacted to at least
the density of ninety-five (95) percent compaction. The layers are not to exceed twelve inches
(12) in depth. Materials used for backfill shall be free from ashes, cinders, refuse, clods, frozen
material, boulders (materials larger than 8” in the greatest dimension) or other materials that are
unsuitable. Sand slurry, without the cement additive, if approved by the city, is the preferred
method of backfill, but the alternative listed above is given for completeness.
C. The City Director of Public Works or his/her designee shall be notified and given the opportunity of
inspection prior to the commencement of each stage of construction.
D. Trench Details for temporary patch, during times when hot mix is unavailable, are the same as indicated
above. Cold mix will be substituted for hot mix. All cold mix patches will be monitored by the Permittee
until spring when the cold patch is removed and a hot mix permanent patch can be made. Permittee is
responsible for both the temporary patch and the permanent repair unless approved otherwise, in writing,
by the Director of Public Works or his/her designee. Permittee is responsible for two years following
acceptance of the trench by the City of Cody.
E. All Permittees working within the City of Cody right-of-way agree by the filling out of the cut/excavation
permit to follow the standards for traffic control as outlined in the MUTCD standards manual. The
2/01/2020
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Permittee must cease all operations if he/she does not comply with traffic control standards. Traffic
control plans and road closure plans will be submitted to the City of Cody prior to starting any work on
the right-of-way. All traffic control devices required to comply with the MUTCD standards are the
responsibility of the Permittee. Barricades, flagging, and cones will NOT be
supplied by the City of Cody.
F. All trench detail information indicated above shall also be applicable for alleys. In addition, all grades
and drainage features shall be returned to their original state. Trenches within alleys, right-of-ways,
dedicated easements, and easements are also still required to be returned to their original state. Trenches
within alleys, right-of-ways, dedicated easements, and easements are also still required to be compacted
to 95%.
G. Excavating under existing curb or gutter shall not be permitted; unless the Permittee will be removing and
replacing the curb and gutter per City specifications.
H. Reference is made to the “Construction Standards” for more details regarding working within the right-of-
way, easement etc.
I. The Permittee agrees to forever indemnify the City of Cody and save it harmless from all liability for
damages to property, or injury or death of persons, including all costs and expenses related thereto,
assisting wholly or in part, or in connection with the existence, construction, alteration, repair, renewal,
use, or removal of the facility by the Permittee or his agents, for those facilities located within the City of
Cody highway, easement or right of way described or noted herein.
J. The Permittee hereby agrees to indemnify and hold harmless the City of Cody against loss, and damage
that arises out of any activities of the Permittee, its agents, employees, and contractors in the
performance of any construction, maintenance, repair, or other work in the City of Cody property,
easement, or right-of-way.
K. Upon completion of the work for which the permit is issued the Permittee shall continue to be responsible
for the site maintenance and repair for the period of two years thereafter.
The undersigned, Permittee/Owner of the facility, hereby accepts this permit, subject to the terms and conditions
stated herein and as provided for in the City of Cody Construction Standards.
Permittee/Owner________________________________________________________________________
Company Name ________________________________________________________________________
BY: ________________________________________________________________________
Date: ________________________________________________________________________
2/01/2020
7
*************************************************************************************************
PLEASE NOTE: IF YOUR ENCROACHMENT PERMIT REQUIRES A STREET CLOSURE, THE
FOLLOWING AGENCIES MUST BE NOTIFIED 48 HOURS PRIOR TO THE CLOSURE:
AGENCY FAX # PHONE # CONTACTED
* WHEN SCHOOL IS IN SESSION
+ IF CLOSURE IS ON THE STATE HIGHWAY SYSTEM
Street closures will not be allowed if prior forty-eight (48) hours notice is not given, except in an emergency. A street
closure shall be defined as any time through traffic is not allowed for a period of two (2) hours or more.
Additionally, the affected homeowners shall be informed by the contractor, on a house-by-house basis, as to the situation,
making them aware of the time of closure as well as the anticipated re-opening.
HOSPITAL/AMBULANCE 578-2485 527-7501
POLICE/FIRE/SHERIFF 527-8708 527-8700
FIRE HALL 527-8785 527-8700
*BUS GARAGE
587-6493
587-2851
PUBLIC WORKS/UTILITIES
527-7349
587-2958
ENERGY WEST (CODY GAS)
587-4563
587-4281
POSTMASTER
587-9332
527-7161
CODY ENTERPRISE
587-5208
587-2231
KODI/KZMQ RADIO
527-5045
578-5000
+ DEPT. OF TRANSPORTATION
527-6028
587-2220
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639 Permit for Excavation of Construction Within a Public way or Public Easement

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Completed 11 July 2020

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