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LEADERSHIP NEWBERG 2004- 05 (City of Newberg)

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0:\engineering\shared\templates\Developement Applications\Subsurface Utility ROW Permit_Application Form
Page 2
“Working Together For A Better Community – Serious About Service”
RIGHT-OF-WAY PERMIT
(Subsurface)
APPLICATION TO PERFORM
SUBSURFACE WORK IN THE PUBLIC
RIGHT-OF-WAY
PERMIT # __________________
RECEIPT # __________________
DATE: _____________________
PUBLIC WORKS DEPARTMENT
ENGINEERING DIVISION
FEE: _______________________
414 E. 1
ST
Street/P.O. Box 970
Expires: ________ Extended: _______
Newberg, OR 97132
NW Natural PLAT # ________________
NW Natural EJL # _________________
PGE WORK ORDER # ______________
Tel: 503-537-1240
Fax: 503-537-1277
INSTRUCTIONS:
Complete SECTION A – APPLICANT, and SECTION B – PROJECT INFORMATION. Incomplete applications may
delay processing of the permit. Please sign in Section E on the reverse side of this form where indicated.
This application shall not become an approved permit until signed by the applicant or an authorized agent
of the company, and authorized by a representative of the City of Newberg. If a certificate of insurance is
not on file with the City, it must be provided before a permit can be issued. Please provide three (3) sets of
construction plans and/or an area map for the proposed work with this completed permit application.
SECTION A – APPLICANT
Check one box below:
Specify name of company: (if not utility company)
Portland General Electric
Frontier
NW Natural
Comcast
Developer
Consultant
Contractor
Business Tel:
24-hr Emergency Tel:
Fax:
Institution Public Agency
SECTION B – PROJECT INFORMATION
Project Location:
______________________________
______________________________
Nearest Cross Street or
Landmark:
______________________
Project Description:
____________________________________
JOB #:______________________________
Purpose of This Application: (check one) ____ Construct ____ Operate ____ Other (see misc. op. below)
Pole line: (Type)
_____________________________
Buried cable: (Type)
_____________________________
Pipe line: (Type)
_____________________________
Misc. Operations: (Maintenance, Repair, Etc. – Describe)
________________________________________________________
Plans Attached (check if yes)
Traffic Control Required (check if yes)
Bond Required (check if yes and indicate amount): $ _____________________
Estimated Dates:
Start Work _____________________
Completion ___________________
Work To Be Performed By: (check one): Utility Company
Sub-contractor: ____________________ Tel: ______________
Field Supervisor: __________ __ Cell Phone: ______________
Detail Location of the Facility: (attach additional sheets if necessary)
Station To
Station
Side of Street
or Angle of
Crossing
Distance From
Buried Cable or Pipe
Pavement
Open Cut
Specify if Bore
or Other
Method
Span
Length
C/L
R/W
Line
Depth
Size & Kind
Yes
No
SECTION C – SPECIAL PROVISIONS (this and next page – attach additional sheets if necessary)
0:\engineering\shared\templates\Developement Applications\Subsurface Utility ROW Permit_Application Form
Page 3
“Working Together For A Better Community – Serious About Service”
SECTION D – GENERAL PROVISIONS
1.
Call the City of Newberg two (2) business days prior to the start of work.
2.
All work shall comply with all applicable provisions of Federal, State and local laws,
regulations, ordinances, and administrative rules.
3.
Oregon State Law requires that excavators notify all underground utilities (1-800-332-2344) two
(2) business days prior to the commencement of any underground excavation.
4.
Provide adequate erosion and sediment control measure at the job site.
5.
Traffic Control shall conform to the requirements of the latest edition of “Manual on Uniform
Traffic Control Devices”. Notify Police Dispatch (503-538-8321) and School District – First Student
Bus Services (503-538-8365) if you propose and receive approval to close the streets.
6.
Pavement cutting will not be allowed without prior written approval, which is given on a
case by case basis only. Open cut on roads newer than five years will not be allowed.
7.
Maintain work zone in a safe manner at all times. Open cuts of pavement within travel
lanes shall be patched with temporary cold mix or covered with steel plates and pinned, to
accommodate traffic overnight or until the required final hot patch is constructed.
8.
A copy of an approved permit and construction plans must be on the job at all times when
work is being performed.
9.
All trenching and pavement cuts shall be guaranteed against settlement for two years after
completion of work and the site fully restored to the original condition or better. Certified
compaction tests by the third party are required.
SECTION E – ACCEPTANCE OF THE TERMS, CONDITIONS AND PROVISIONS
The Applicant shall indemnify and hold harmless the City of Newberg, its Council, its officers and
employees from all suits and actions; or claims of any character brought because of any injuries
or damages received or sustained by any person, or property on account of the operations of
the said Applicant, his/her subcontractors or employees of either, or on account of, or in
consequence of any neglect in safeguarding the work; or because of any act or omission,
neglect or misconduct of the said Applicant. By signing below, the Applicant accepts and
approves all the terms, conditions, and provisions contained and attached hereto, including the
“SPECIAL PROVISIONS” under SECTION C, and the City’s adopted Design Standards. Permit for
construction will expire one (1) month from the Date of Issue unless the Applicant submits a
reasonable justification for a longer timeframe at the first application. A maximum of one year
may be granted upon request.
Applicant’s Signature:
Date:
Title (owner(s) / authorized agent):
SECTION F – CITY’S USE
Insurance Certification on File:

Submitted Herewith:

Attached Standard Drawings:
_____________________________________________________________
Permit Issued By:
Title:
Date of Issue:
********************************
*** WHEN APPROVED ***
*** AFFIX AGENCY STAMP ***
********************************
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LEADERSHIP NEWBERG 2004- 05 (City of Newberg)

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Completed 24 January 2021

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