PO Box 458 * Veneta, OR 97487 * 541-935-2191 * 541-935-1838 * www.VenetaOregon.gov
Permit No. ________________
Applicant
Contractor
Address
Address
Phone
Phone
$40 FEE + RESTORATION DEPOSIT (Below)
Date/Rec#
Location Address
Assessor’s map & tax lot number
TYPE OF CONSTRUCTION
Check appropriate box(s)
Opening Paved Street .................................................. (Minimum Deposit: $200 per VMC Chapter 12.05.100)
Opening Unpaved Street ............................................... (Minimum Deposit: $150 per VMC Chapter 12.05.070)
Curb Cuts Number of Cuts __________ Cut Width ________________feet
Private Construction of Driveway or Driveway Culvert
Private Construction of Sidewalk
Other
INSURANCE WAIVER:
I, __________________________________________, agree to save the City, its officials, employees, and agents
harmless from any and all costs, damages and liabilities which may accrue or be claimed to accrue by reason of any
work performed under this permit. I am also aware of all requirements of the Veneta Municipal Code Chapter 12.05.
_______________________________ ________________
Signature Date
VIOLATION-PENALTY Any person, firm or corporation who shall violate, fail, neglect or refuse to comply with any of
the provisions of Chapter 12.05 shall be guilty of a misdemeanor and upon conviction thereof shall be punished by a
fine not to exceed $200, or by imprisonment not to exceed 100 days, or by both such fine and imprisonment. Each
day during which any violation continues or persists, after being given due notice, constitutes a separate and distinct
violation.
Public Right-of-Way Construction
Application & Permit
S:\FORMS\PUBLIC WORKS\RIGHT-OF-WAY PERMIT CONSTRUCTION PERMIT.DOC
CONTRACTOR SHALL PROVIDE:
Contractor License Number and expiration date:
Contractor’s Insurance Company and Policy Number:
Amount of Insurance carried by Contractor:
Start Date:
CONTRACTOR MUST FOLLOW THE FOLLOWING PROCEDURE:
(1) Notification of Public Works Department of project start date.
(2) Notification of project inspection during construction.
(3) Notification of project completion date.
(4) Notification for Final inspection and approval.
(6) Provide set of as-built plans to the City at the completion of the project, if applicable.
(7) Excavators are required to locate and protect all existing underground utilities. You may be held liable for
damages. Call for utility locates before you dig. 811
TO BE COMPLETED BY STAFF
ADDITIONAL REQUIREMENTS
Additional Insurance Required by City in the amount of:
Bonding required by the City in the amount of:
Attach Construction Plans
Other:
No movement of vehicles or equipment across curb except at approved driveway opening
No storage of materials or equipment in the street
No operation of tracked vehicles or equipment within the street
Contractor responsible for keeping street clean at all times
If insurance is required, prior to starting any work in the right-of-way, you will need to provide the City of Veneta with
an insurance certificate naming the City as additional insured. Failure to provide insurance is cause to cancel this
permit.
APPROVED BY:
_______________________________ ________________
Public Works Superintendent Date
** THIS PERMIT IS NOT TRANSFERABLE **
S:\FORMS\PUBLIC WORKS\RIGHT-OF-WAY PERMIT CONSTRUCTION PERMIT.DOC