Fillable BOROUGH OF WILKINSBURG (Borough of Wilkinsburg)

Fill Online, Printable, Fillable, Blank BOROUGH OF WILKINSBURG (Borough of Wilkinsburg) Form

Use Fill to complete blank online BOROUGH OF WILKINSBURG (PA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

BOROUGH OF WILKINSBURG (Borough of Wilkinsburg)

On average this form takes 13 minutes to complete

The BOROUGH OF WILKINSBURG (Borough of Wilkinsburg) form is 5 pages long and contains:

  • 0 signatures
  • 25 check-boxes
  • 42 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Borough of Wilkinsburg

BROWSE BOROUGH OF WILKINSBURG (PA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Revised 1/20/2017
BOROUGH OF WILKINSBURG
CODE ENFORCEMENT DEPARTMENT
ROOM 304 THIRD FLOOR
605 ROSS AVENUE
WILKINSBURG PENNSYLVANIA 15221
PH 412-244-2923/FX 412-244-2922
STREET AND SIDEWALK OPENING PERMIT APPLICATION
In accordance with Chapter 226 in Borough Code of Ordinances
APPLICATION DATE: _____________________ PERMIT #____________________________
Applicant Name________________________________________ Phone # ______________________
Applicant Address__________________________ City ________________State_______ Zip ________
E-mail ___________________________ PA One Call Serial # ___________________________________
Site Location Address _________________________________________________________________
(CLOSEST PHYSICAL ADDRESS)
PRIVATE PROPERTY WORK
Property Owner’s Name _____________________________ Phone # ___________________________
Property Owner Address_____________________________ E-mail ____________________________
Submittal Requirements
The following documentation is required for a complete application:
□ Plan or schematic showing limits of work, location and dimensions of opening
□ Bond of approved surety or Trust Company which must remain in effect 24 months after permanent
resurfacing:
$3000.00 per opening
$10,000.00 for indefinite number of openings
□ Certificate of Insurance
Revised 1/20/2017
Type of Request (Check appropriate box and fill-in the blanks):
□ Emergency street/sidewalk opening
□ Borough Road hole at or under 50 sq. feet
□ Borough right-of-way: hole at or under 50 sq. ft.
□ Any street or right-of-way opening in excess of 50 sq. feet constitutes a separate
opening.
□ Sidewalk/ grassy area: hole under 10 linear feet
□ Sidewalk/ grassy area: hole 10 linear feet and over
Start date: _________ Size of opening ____ ft. X ___ ft. Total square feet of opening area: _________
Description of work to be done ________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Inspection required before back-fill.
Fill Date ______________________ Temporary Resurface Date __________________________
The trench shall be backfilled in accordance with the specifications regulating street excavations within the
Borough of Wilkinsburg.
Safeguards required for permits
A. All gutters shall be left open so as not to obstruct the free passage of water, and the sidewalks and
footways must be kept in a safe and passable condition. All excavations or material from them shall
have placed on them sufficient lights and barricades to identify them from all directions during the day
and after dark.
B. If, for safety purposes, the Department deems it necessary to install additional warning devices such
as lights, barricades or signs, the permittee shall be notified of the decision and shall receive
instruction on the installation. In case of emergencies, the Borough may install all additional warning
devices deemed necessary by the Department. The Borough shall invoice the permittee for rental and
installation costs incurred from the date of installation until the permittee installs warning devices.
C. If the permittee fails to install such devices, the Borough shall invoice the permittee for rentals and
installation costs incurred from the date of installation until the date of removal. Payment not made by
the permittee within 30 days of the invoice date will be chargeable against the posted bond, including
all fees and costs involved in the collection of this payment.
Revised 1/20/2017
CONTRACTOR INFORMATION
Business Name:_____________________________________
PA Cont. Reg.#: _________________
Name: _____________________________________________
Phone#:___________________________
Address:____________________________________________
Fax #: ____________________________
City/State/Zip: _______________________________________
E-mail:____________________________
Existing Condition
□ Borough Road:
Type: □ Brick
□ Concrete
□ Blacktop
□ Sidewalk/ grassy area
All surfaces shall be restored to the original conditions upon completion of the work.
Fees
□ Borough Road: hole at or under 50 sq. ft $300
□ Borough ROW: $300/hole over under 50 sq. ft.
Any street or right-of-way opening in excess of 50 sq. feet constitutes a separate
opening and additional $300 fee. Any fee exceeding $10,000 may be negotiated with
the Borough.
□ Sidewalk/ grassy area: $10/hole under 10 linear feet $10
□ Sidewalk/ grassy area: $10/hole under plus $1.00/foot over 10 feet. TBC
Revised 1/20/2017
WORKERS’ COMPENSATION ADDENDUM
(Required to be attached to all permit applications)
Part 1
The Applicant for the permit, in compliance with Act 44 of 1993, hereby submits, (check one):
□ Certificate of Insurance OR Certificate of Self-Insurance Listing the Borough of Wilkinsburg and our
Third (Must Attach) demonstrating applicant is insured against claims for personal injury as well as
against claims for property damages which may arise from or out of the performance of the
excavation work, whether such performance be by the applicant or by anyone directly or indirectly
employed by him. Such insurance shall include protection against liability arising from completed
operations, underground utility damage and collapse of any property. Liability insurance for bodily
injury shall be in an amount not less than $300,000 for each person and $300,000 for each accident,
and for property damages an amount not less than $100,000. Failure of an applicant to file a certificate
of insurance shall be sufficient reason for denying said permit. The applicant shall save harmless the
Borough from any and all damages and liability by reason of personal injury or property damage
arising from work done by the applicant under the provisions of this article.
□ Affidavit of Exemption
Part 2
Basis and Affidavit of Exemption
□ Applicant is an Individual who owns the property
□ Contractor/Applicant is a sole proprietorship without employees
□ Contractor/Applicant is a corporation, and the only employees working on the project have and are
qualified as “Executive Employees” under Section 104 of the Worker’s Compensation Act.
□ All of the Contractor/Applicant’s employees on the project are exempt-on religious grounds under
Section 304.2 of the Worker’s Compensation Act.
□ Other: Please explain:_______________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
My signature on behalf of or as the Contractor/Applicant for this permit constitutes my varication that
the statements contained herein are true, and that I am subject to the penalties of 18 Pa. C.S.A. 4904
relating to unsworn falsification to authorities.
Applicant Signature
Print Name: ___________________________________________
Signature: ____________________________________________ Date: ______________
Revised 1/20/2017
For Office Use Only
Permit Number __________
Fee Paid $ ______________
Approved By: __________________________________________ Date: __________
Title: _________________________________________________
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

BOROUGH OF WILKINSBURG (Borough of Wilkinsburg)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 17 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document