This application form is a quadruplicate copy, self-carbonized form. After Sections I and II are completed by the applicant, the first three
copies
(white, yellow and pink) should be submitted to the City of Winter Garden Engineering Department with proof of fee
payment, and
subsequent
issuance of a permit(*). All fees should be paid at the City Municipal Complex. The fourth copy (gold} should be retained by the
applicant,
(white) becomes the approved permit, when Section Ill has been completed by the City of Winter Garden Engineering
Department.
Either the permit, or a copy thereof, must be available, at all times, at the worksite where the work is being preformed.
(*)LATE CHARGE:
This application should be submitted electronically to the City of Winter Garden at the following address: engineering@cwgdn.com. All fees (if
required) should be paid at the City of W inter Garden Municipal Complex, 300 West Plant Street, Winter Garden, Florida, 34787 prior to
issuance of permit. The approved permit or a copy thereof is required to be available at the construction location when the work is being
performed.
The applicant is required to give the City of Winter Garden a minimum of 24 HOUR NOTICE PRIOR TO COMMENCEMENT OF WORK. Failure
to notify the City of Winter Garden in advance may result in immediate suspension of work.
INSTRUCTIONS AND CONDITIONS
THE ISSUANCE OF THIS PERMIT IS GOVERNED BY AND REGULATED BY THE FOLLOWING APPLICABLE DIRECTIVES:
Florida State Statutes
Chapter 77-153, Laws of Florida, Protection of Gas Pipelines
Orange County Code, Underground Utility Pipeline Contracting
Orange County Standards & Specifications for Sewerage & Water Facilities as Adopted and Modified by the City
Orange County Road Construction Specifications as Adopted and Modified by the City
Orange County, Right of Way Utilization Regulations as Adopted and Modified by the City
Regulations for the Transportation of Natural and Other Gas by Pipelines (Parts 191 and 192, Title 49 of the Code
of Federal Regulations)
AND ANY ADDITIONAL REQUIREMENTS OF THE CITY COMMISSION.
SECTION I GENERALINFORMATIONANDINSTRUCTIONS
To be completely filled out by all applicants.
Any work that commences without the required permits available on the job site shall be immediately suspended until such time as the
required permits have been acquired. A late charge for work commenced without a valid permit issued shall be charged in addition to the
normal permit fee. The late charge shall be as prescribed by the City Commission. Emergency work is excluded from late charges.
SECTION II CONDITIONS
It is understood and agreed that the rights and privileges herein set out are granted only to the extent of the City's right, title and interest in
the land to be entered upon and used by the permittee; and the permittee will at all times, assume all risk of and indemnify, defend, and save
harmless the City of W inter Garden from and against all loss, damage, cost or expense arising in any manner on the account of the exercise
or attempted exercise by said permittee of the aforesaid rights and privileges.
All permit applications will be reviewed by the Engineering Department and approvals or requests for additional information will be sent to the
applicant at the email address provided in this Section.
Applicant declares that prior to filing this permit, if the proposed work is within public right of way, he has ascertained the location of all
existing utilities, both aerial and underground. The specific names of the agencies that have been notified must be typed or printed in the
space provided, for the specific type utility. A gas ID number is required.
It is expressly stipulated that this permit is a license for permissive use only and that the placing of facilities upon public property pursuant to
this permit shall not operate to create or to vest any property right in said holder.
The construction and/or maintenance of a utility shall not interfere with the property and right or prior occupant.
Inthe event of widening, repair or reconstruction of a public road or highway, upon reasonable notice the permittee shall move its facilities
to clear such construction at no cost to the City of W inter Garden, insofar as such facilities are within the public right of way.
The holder of this permit shall take such safety measures, including the placing and display of caution signs and signals as are required by
the Manual on Uniform Traffic Control Devices for Streets and Highways, when working in public right of way, and shall also prevent any
obstructions or conditions which are or may become dangerous to the traveling public.
FEES will be computed in accordance with the schedule of fees adopted by the City Commission and are payable upon submission of
permit application.
SECTION Ill ENGINEERING DEPARTMENT USE ONLY
Applicant's additional requirements (if any); and expiration date; to be completed by the City of Winter Garden Engineering Department.
SECTION IV ENGINEERING DEPARTMENT USE ONLY
Completion Certificate - To be completed by the City of Winter Garden Engineering Inspector.
SECTION
III
OFFICE USE ONLY
APPROVED ON SUBJECT TO GENERAL LAW AND THE FOLLOWING ADDITIONAL REQUIREMENTS:
THIS PERMIT EXPIRES ON
NOTE
: Notify the Inspection Section of the Engineering Department at least
24 HOURS prior to beginning construction. Call 407-656-4111 ext. 5463.
All materials must be inspected prior to installation.
APPROVED BY:
SECTION IV PERMIT COMPLETED
For the City Engineer
PERMIT NOT COMPLETE
EXPIRED
Comments:
Date
Engineering Inspector:
*
IMPORTANT: SEE INSTRUCTIONS AND CONDITIONS ON REVERSE OF THIS FORM
*
CITY OF WINTER GARDEN
RIGHT OF WAY UTILIZATION - UNDERGROUND UTILITY PIPELINE CONSTRUCTION PERMIT APPLICATION
(SUBMIT TYPEWRITTEN OR PRINTED IN TRIPLICATE WITH FOUR SETS OF PLANS)
CHECK APPPOPRIATE BOX
Right of W ay Utilization
Underground Utility
Pipelin
e Construction
Firm Name
Phone No
SECTION
I
GENERAL INFORMATION
Applicant's Name:
Address:
Description of Proposed Work:
Scheduled Start Date:
Construction/Installation Location:
SECTION:
TOWNSHIP SOUTH
SECTION II COMPLETE APPLICABLE SECTIONS
Number and Type of Underground Road Crossings
RANGE EAST
NONE
OPEN CUT
(PAVED)
OPEN CUT
(UNPAVED)
BORE/JACK
OTHER
(Specify)
I certify that all other right of way users and municipalities in the immediate vicinity of the proposed construction/installation, have been
notified in writing on of the proposed work, by the applicant, in order to determine if there are any objections to
(Date)
the proposed construction/installation, including the franchised gas company, whose name and Gas I.D. Number is furnished herewith.
ID# GAS ID# GAS
Email:
Title of Approved Plans and Date of City Engineer 's Approval (if applicable
Construction Cost (Contract Amount - Includes Labor, Materials, etc.)
$
Date: Applicant 's Signature:
Title:
OFFICE USE ONLY
Permit No.
FEE$
District No.
Permit No.
FEE$
District No.