K:\City\Engineering-PW\Right of Way Permit Application 2018.doc Rev. 06/2018
CITY OF PORTAGE, WISCONSIN
APPLICATION FOR UTILITY CONSTRUCTION IN CITY RIGHT-OF-WAY
1. APPLICANT INFORMATION Date of Application____________________________
Company_______________________________ Address______________________________________
Contact Person___________________________ ______________________________________
Phone__________________________________ Fax__________________________________________
2. CONTRACTOR INFORMATION
Contractor to Perform Work_________________________________________________________________________
Contact Person________________________________________ Phone________________________________________
3. PROPOSED WORK
A. SCHEDULE Estimated Start Date________________ Estimated Completion Date_________________
*Permit Expiration Date_____________________
*Permit is valid for 30 days unless otherwise provided (per Section 66-54(d) of the Code of Ordinance)
B. ADDRESS(ES) OR LOCATIONS OF PROPOSED WORK
____________________________________________________________________________________________
____________________________________________________________________________________________
C. TYPE OF FACILITY (Check all boxes that apply)
Water Hydrant Sanitary Sewer Storm Sewer Utility Service Connection
NGas Electric Telecommunications CATV Sewer and/or Water Lateral
Fiber Optic Other_________________________________________________________________________
D. PURPOSE (Check all boxes that apply)
Install Repair Replace Abandon Other_________________________
E. LIMITS OF WORK (Check boxes that apply)
Driving Lane Parking Lane Terrace Sidewalk Easement/Greenway
Other_____________________________________________________________________________________
F. TRENCH TYPE AND/OR BORE (Attach dimensional sketch)
Asphalt (Open Cut) Concrete (Open Cut) Green Space (Open Cut)
Bore
4. APPLICATION CHECKLIST (The following items are required)
Call Diggers Hotline at 800-242-8511.
No permits between 11/30 and 4/1, unless an emergency.
Attach dimensioned sketch identifying the proposed work area and improvements.
Identify location of proposed boring(s).
Identify any proposed new surface structures or abandonment and removal of structures.
Certificate of Insurance, per Ordinance with City named as additional insured ($500,000 per person, $500,000 property damage,
$500,000 per incident).
Read and comply with Portage Standard Specifications, General Permit Provisions and Conditions of Issuance.
Indemnity Bond in the amount of the cost of the project (minimum $5,000) or $1,000 cash deposit.
Application fee of $150 attached.
*Cash deposit of $1,000 attached or provide bond above.
*If payment is made by check, attach a photo copy of the check on the back of the permit.
5. PROJECT/CONSTRUCTION CHECKLIST - REQUIRED INSPECTIONS (Sewer, Water, Sidewalks, Driveway Aprons)
Traffic Control
Initial Excavation
Backfill Compaction
Field Inspection required during
Construction
Follow-up Inspection After All Restoration Is Fully Established
For Office Use Only
Approval of Work Completed: _________________________________________ _______________________
P.W. Superintendent or Engineer Tech. Date
Deposit Returned: ________________________________________ __________________________
Treasurer Date
K:\City\Engineering-PW\Right of Way Permit Application 2018.doc Rev. 06/2018
6. SPECIAL CONDITIONS
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
In consideration of being permitted for utility construction, the permit holder hereby agrees that it will faithfully comply with the terms of the permit
as issued by the City of Portage, Section 66-54 of the City’s Code of Ordinances, including the General Permit Provisions and Conditions of Issuance
and any Special Provisions; that it will comply with all applicable statutes, ordinances, rules and regulations of the State of Wisconsin and the City of
Portage; that it will indemnify, defend and hold the City of Portage harmless from any and all claims, liability, loss, damage or expense incurred by
the City of Portage on account of any injury or death of any person or any damage to property caused by or resulting from activity or work performed
under this permit, and that it hereby agrees to purchase comprehensive public liability insurance showing the City of Portage as an additional insured
and shall provide thirty (30) days written notice to the City upon cancellation or material change in the policy; that it will at all times keep the place
where such excavation or construction is made properly guarded by day and lighted by night; that it will leave the street, sidewalk, alley, or terrace in
as good or better condition than existed when the work was commenced; that all restoration of the street, sidewalk, alley or terrace affected by acting
upon this permit shall be completed within fifteen (15) calendar days of the closing of the excavation; the permit holder shall guarantee their work
and shall maintain it for twelve (12) months following the date of completion and acceptance by the City; that if this project requires a detour, it will
provide the City Engineer seventy-two (72) hours notice prior to commencement of; that it agrees this permit may be voided by the City Engineer if
the work is not started within a reasonable length of time after the above-stated starting date; and that it will comply with City Standard
Specifications, General Ordinances, Erosion and Stormwater Runoff Control, as well as State and Federal Rules and Regulations, as may apply. This
permit is valid for 30 days unless otherwise provided per section 66-54(d) of the City of Portage Code of Ordinances. If not completed within 30
days, the City shall retain the cash deposit and a new permit will need to be obtained. AT THE COMPLETION OF A PROJECT, ALL UTILITY
FLAGS FROM DIGGERS HOTLINE TICKETS SHALL BE REMOVED AND DISPOSED OF AT THE CONTRATOR’S EXPENSE.
Date of Application________________________________________________________________________________________
Signature of Authorized Permit holder Representative________________________________________________________________
Please Print Name and Title of Authorized Permit holder Representative_________________________________________________
Please contact the following City Staff for inspections:
Technical
Public Works Superintendent (Sewers) Kim Standke (608)742-8486
City Forester Dan Kremer (608)742-2178
Water Superintendent (Water Main) Kevin Bortz (608)742-4727
Engineering Department (Field Inspection) Erin Salmon (608)742-2176, ext. 268
Administrative
Public Works Secretary (Permits) Tammy O’Leary (608)742-2176, ext. 322
City Engineer (Permits) Aaron Jahncke (608)742-2176, ext. 325
Submit completed application to:
City of Portage
Attn: Tammy O’Leary
115 West Pleasant Street
Portage, WI 53901
Reviewed by: __________________________________________________ Date:___________________________________
P.W.
Superintendent or Engineer Tech.
Approved by: ___________________________________________________ Date: __________________________________
City Engineer
-----------------------------------------------------------------------------End of Application--------------------------------------------------------------------
The following page to be given to applicant/contractor
click to sign
signature
click to edit
K:\City\Engineering-PW\Right of Way Permit Application 2018.doc Rev. 06/2018
---------------------------------NOTICE TO CONTRACTOR-------------------------------
*Permit Expiration Date_____________________
*Permit is valid for 30 days unless otherwise provided (per Section 66-54(d) of the Code of Ordinance)
The Owner/Contractor must call to schedule these required inspections:
- Sewer Lateral work in the R.O.W. shall be inspected by the Engineering Department
- Water Lateral work in the R.O.W. shall be inspected by the Engineering Department
- Sidewalkforms need to be checked prior to pour
- Curb Modificationforms and widths to be confirmed prior to pour
- Asphalt Patch Work depths need to be confirmed prior to paving
- Driveway Apron - forms and widths to be confirmed prior to pour
The Owner/Contractor must call to schedule a final restoration inspection prior to
the return of the $1,000 deposit. If not completed within 30 days, the City shall
retain the cash deposit and a new permit will need to be obtained.
This also includes all utility flags from diggers hotline tickets be removed and
disposed of.
(If none of the above apply, please dismiss this notice)
Call the City for inspections from 7:00 – 3:30, Monday-Friday
Phone: 608-742-2176, ext. 268
Contact: Erin Salmon
Please provide address, type of inspection and name of contractor.
If any questions, we can have an on-site meeting prior to construction.
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