CITY OF DUBLIN
GENERAL RIGHT-OF-WAY APPLICATION
Exhibit "A"
APPLICANT INFORMATION: (please print or type)
Corporate Name: Phone #
Corporate Address: Fax #
Contact Person: Phone #
Contact Person Address: Fax #
Contact Person E-mail:
Ohio Utilities Protection Service Registration # (if applicable)
24 Hour Emergency Contact People (in order to be contacted)
Name Business # Residence # Pager# Mobile#
1
2
3
TYPE OF PERMIT APPLYING FOR
FEE *
General right-of-way (with a Service Permit) $745
General right-of-way (without a Service Permit) **
Special Right-of-Way
Utility Right-of-Way (a brief statement explaining why the Applicant is entitled
to this type of Permit is required Exhibit M.)
**Fees for facilities not in the
DubLink system are:
Less than 1 mile
$10,000
From 1-10 miles $17,500
From 11-100 miles $35,500
From 100-500 miles $100,000
* Please note all application fees must be paid at the time the application is submitted.
LENGTH OF PERMIT TERM:
MAXIMUM ALLOWABLE (Check One)
GENERAL PERMITS (5 years)
SPECIAL PERMITS (no limit)
UTILITY PERMITS (coterminous with Service Agreement)
SHORTER TERM AS REQUESTED HEREIN (define)
THE FOLLOWING INFORMATION MUST BE PROVIDED, LABELED AND IDENTIFIED IN THE ORDER AND
MANNER SHOWN BELOW FOR YOUR APPLICATION TO BE CONSIDERED "COMPLETE". AN OFFICER OF
THE COMPANY OR OTHER LAWFULLY AUTHORIZED INDIVIDUAL MUST SIGN YOUR APPLICATION.
General Right-of-Way Permits will require the following Exhibits: B (in place of C, D, E, H); F; G; I; J; K; L and M
(when requested).
Special Right-of-Way Permits will require the following Exhibits: B (in place of C, D, E, H); F; I; J; L and M (when
requested).
Utility Right-of-Way Permits require the following Exhibits: B (in place of C, D, E, H); F; G; I; J; K; L and M (when
requested).
The information contained in this Application is true and correct to the best of my knowledge.
Signature
Date:
Typed Name &Title
Exhibit B
Copy of valid Certification from the Public Utilities Commission of Ohio
Exhibit C
Statement of Applicant’s corporate or other business entity or organization, including but not limited to, names, titles,
and business addresses of all officers, and/or directors of the applicant.
Exhibit D
Detailed description of the applicant’s previous experience in providing related and/or similar services as t hose
proposed in conjunction with said application.
Exhibit E
Financial statement
Exhibit F
A statement certifying the Applicant is not delinquent on a ny taxes or other obligations to the City of Dublin or
Franklin, Delaware, or Union Counties.
:
Exhibit G
A statement identifying any Service Permits awarded to the Applicant, from the City of Dublin, in accordance with
Chapter 98 of the Codified Ordinances of the City. A copy of said ordinance granting such Service Permits shall also
be attached and provided herewith.
Exhibit H
Proposed plan of operation of the applicant.
Exhibit I
A detailed map of facilities in or proposed to be in the Right-of-Way, prepared in accordance with the “Mapping
Requirements” section (section 5) of the Rules and Regulations.
Exhibit J
A non-refundable Application Fee (initial, renewal, and/or transfer) in the form of a check, money order or wire
transfer made payable to the City of Dublin.
Exhibit K
Applicant shall provide a certificate of insurance for all required insurance. Please note, those Applicants maintaining
a book value in excess of ten million dollars ($10,0000,000) may submit a statement requesting to self-insure, thereby
seeking exemption from the insurance requirements required herein.
Exhibit L
Explanation of why the applicant is entitled to a “Utility Right-of-Way” permit
Exhibit M
Additional information requested by the City of Dublin.
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