Fillable Application for Right-of-Way Permit (City of Parkville)

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Application for Right-of-Way Permit (City of Parkville)

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File type: PDF

U.S.A. forms for City of Parkville

BROWSE CITY OF PARKVILLE (MO) FORMS

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Application #: ________________
Date Received: ______________
Date Approved: ______________
Permit #: ____________________
Application for Right-of-Way Permit
Use of (storage of dumpsters, storage containers or similar) or work within (grading, cuts, tunnels, excavation or
similar) the public right-of-way is regulated by Parkville Municipal Code. Accordingly, anyone proposing to use
or work within the right-of-way shall submit the following application and obtain a right-of-way permit from the
Parkville Public Works Department prior to commencement of that use or work.
1. Applicant / Contact Information
Applicant(s) Primary Contact(s), if not applicant
Name: __________________________________ Name: _________________________________
Company: _______________________________ Company: ______________________________
Address: ________________________________ Address: _______________________________
City, State, Zip: ___________________________ City, State, Zip: __________________________
Phone: ____________ Fax: _______________ Phone: ______________ Fax: ______________
Emergency #: ____________________________ Emergency #: ___________________________
E-mail:__________________________________ E-mail: _________________________________
Alternative Contact Alternative Contact
Name: __________________________________ Name: _________________________________
Phone: _________________________________ Phone: _________________________________
I, the undersigned, do hereby authorize the submittal of this application and associated documents and certify
that all information contained therein is true and correct. I do hereby agree to abide by and comply with all
applicable Municipal Codes and conditions of approval. I understand that any violations shall constitute cause
for issuance of fines and pursuit of civil remedies as may be applicable.
Applicant’s Signature (Required) _________________________________ Date: _____________
2. Work Description Information
Location (may be attached): ___________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Description (may be attached): _________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Projected work date/times(s): __________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Protective measures: ________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
M:\Fillable Forms\ROW permit app v10-20-14.docx Last revised October 20, 2014
Application #: ________________
Date Received: ______________
Date Approved: ______________
Permit #: ____________________
3. Checklist of submittals required at time of application
Completed application.
Authorization signature of the applicant.
Nonrefundable permit fee in the amount of $10.00.
For ROW use only – A map / diagram showing: the proposed location of the use and size of
equipment; affected properties (by address or lot number); protective measures proposed.
For ROW construction only – Plans and specifications showing all proposed work in the right-of-
way including: a map / diagram showing the proposed locations, dimensions, depth and nature of
any work; affected properties including address or lot number; method of notification; protective
measures, including warning and safety devises; and method of filling and restoring the surface
after work is completed.
For ROW construction only - deposit or bond in the amount of $500.00 for any cuts, tunnels or
excavation in, through or under any street, sidewalk, alley or similar public place.
For ROW construction only – a certificate of insurance naming the City as an additional insured with
the following minimum coverage: comprehensive general liability/ personal injury coverage of
$100,000.00 each person and $300,000.00 each occurrence; and property damage coverage of
$50,000.00 each accident and $100,000.00 aggregate.
For City Use Only
Application accepted as complete by: _____________________________________ Date: ______________
Required approvals, if applicable:
Public Works Director (all): Action: __________ Date: _________
Conditions: ______________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Police Department (closures/public safety): Action: __________ Date: _________
Conditions: ______________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Fire Department (closures/public safety): Action: __________ Date: _________
Conditions: ______________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Other (_________________________): Action: __________ Date: _________
Conditions: ______________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Other (_________________________): Action: __________ Date: _________
Conditions: ______________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Other (_________________________): Action: __________ Date: _________
Conditions: ______________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
M:\Fillable Forms\ROW permit app v10-20-14.docx Last revised October 20, 2014
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Application for Right-of-Way Permit (City of Parkville)

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Completed 19 January 2021

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