Fill - Free fillable Public Rights-Of-Way Construction Permit (City of Stephenville) PDF form

298 W. Washington

Stephenville, Texas 76401

254-918-1220 Ph.

254-918-1207 Fax

Public Rights-Of-Way Construction Permit

1. Provider Classification:

a. Franchised or Licensed Company:

b. Certified Telecommunications Provider:

c. Contact Person:

2. Applicants Name (or Agent/Contractor of #1):

Company Name:

Applicant’s Name:

24 Hour Emergency Phone Number:

3. Project Location:

a. Location and general description of work in the Public Right-of-Way (Include linear

feet of facilities in the Right-of-Way, if applicable): ___________________________

_____________________________________________________________________

b. Will work involve removing and/or excavating any pavement, curb and gutter, or

sidewalk? Yes No

If yes, give detailed location:

c. Will your work involve blocking the Public Right-of-Way?

Yes No

If yes, give street address and nearest street intersection:

d. Anticipated Work Duration:

i. Start Date:

ii. Finish Date:

Date Received: _________________________ Received By: _______________________________

Title: _______________________________ Department:

298 W. Washington

Stephenville, Texas 76401

254-918-1220 Ph.

254-918-1207 Fax

Page 2 of 6

4. Requirements:

Two (2) Copies of construction plans and two (2) maps to be submitted with application.

Submittals shall be submitted electronically in PDF via confirmed email or flash drive.

Surrounding underground services must be located.

Proof of insurance is attached or on file.

The contractor shall contact the Public Works Office and Utility Superintendent at

254-918-1292 and 254-918-1235 respectively at least 48 hours in advance of the start of

the project unless authorized by the city.

This permit will become null and void if construction has not begun within 90 days.

Above ground route/location markers are not permitted, except as required by law.

Applicant shall indemnify and forever hold the city harmless against each and every claim, demand

or cause of action that may be made or come against it by reason of or in any way arising out of

the closing, blocking, excavating, cutting, tunneling, or other work by the applicant under permit

from the City if such permit is granted unless otherwise provided in law.

Signed: Printed:

Authorized Agent of Provider

Date:

NOTE: Emergency Work: Permit to be taken out the next business day.

298 W. Washington

Stephenville, Texas 76401

254-918-1220 Ph.

254-918-1207 Fax

Page 3 of 6

Exhibit A

PROOF OF INSURANCE AND BONDS

1. An applicant shall obtain and maintain insurance in the following amounts with a company

authorized to do business in the state of Texas acceptable to the City.

2. Each policy must include a cancellation provision in which the insurance company is required

to notify the city in writing, not fewer than thirty (30) days before canceling, failing to renew, or

reducing policy limits. Each policy shall provide that notice of claims shall be provided to the

City Administrator by certified mail.

3. The applicant shall file the required original certificate of insurance prior to any commencement

of work. The certificate shall state the policy number; name of insurance company; name and

address of the agent or authorized representative of the insurance company; name, address and

telephone number of insured; policy expiration and specific coverage amounts. The certificate

shall name the City and its officers, employees, board members and elected representatives as

additional insured for all applicable coverage. The city may request the deletion, revision or

modification of particular policy terms, conditions, limitation or exclusions unless the policy

provisions are established by law or regulation binding the city, the applicant or the underwriter.

If the city requests a deletion, revision or modification, the applicant shall exercise reasonable

efforts to pay for and accomplish change.

General Liability (including Contractual

Liability Written on an occurrence basis)

Automobile Liability; including any auto,

hired autos and non-owned autos

Excess Liability, Umbrella Form

Worker’s Compensation and Employer’s

Liability

General Aggregate 2 M

Product/Comp./Op. Agg. 2 M

Personal & Adv. Injury 1 M

Each Occurrence 1 M

Combined Single Limit 1 M

Each Occurrence 2 M

Aggregate 2 M

Each Accident .5 M

Disease-Policy Limit .5 M

Disease-Policy Employee .5 M

298 W. Washington

Stephenville, Texas 76401

254-918-1220 Ph.

254-918-1207 Fax

Page 4 of 6

4. Applicant shall obtain and maintain, at is sole cost and expense, and file with the Planning and

Building Services Department, a corporate surety bond in the amount $1,000,000 both to

guarantee timely construction and faithful adherence to all requirements of this ordinance. The

bond amount may be reduced to $50,000 after a period of two (2) years provided applicant has

complied with all terms and conditions herein. The bond shall contain the following

endorsement: "It is hereby understood and agreed that this bond may not be cancelled by the

surety nor any intention not to renew be exercised by the surety until thirty (30) days after receipt

by the city of such written notice of such intent." The bond shall provide, but not be limited to,

the following condition: There shall be recoverable by the city, jointly and severally from the

principal and the surety, any and all damages, loss or costs suffered by the city resulting from

the failure of the applicant to satisfactorily construct facilities and adherence to all the

requirements of this ordinance. The rights reserved to the city with respect to the bond are in

addition to all other rights of the city, whether reserved by this ordinance, or authorized by law;

and no action, proceeding or exercise of right with respect to such bond shall affect any other

rights of the city.

5. The City Administrator or his/her designee may waive or reduce the above requirements, taking

into consideration both that the applicant has furnished the city with reasonable documentation

to evidence adequate financial resources substantially greater than the insurance and bonding

requirements, and has demonstrated in prior rights-of-way construction activity, prompt

resolution of any claims and substantial compliance with all required applicable codes and

ordinances.

6. The city reserves the right to review the insurance requirements during the effective period of

any franchise or municipal consent agreement, and to reasonably adjust insurance coverage and

limits when the City Administrator determines that changes in statutory law, court decisions, or

the claims history of the industry or the provider require adjustment of the coverage. For

purposes of this section, the city will accept certificates of self-insurance issued by the State of

Texas or letters written by the applicant in those instances where the State does not issue such

letters, which provide the same coverage required herein. However, for the city to accept such

letters, the applicant must demonstrate by written information that it has adequate financial

resources to be a self-insured entity as reasonable determined by the city, based on financial

information requested by and furnished to the city.

7. The financial and insurance requirements may be met by applicants with a current franchise or

license and applicants governed by Chapter 283 of the Texas Local Government Code if the

current franchise, license or statutory indemnity adequately provides for insurance or bonds or

provides an indemnity in favor of the city.

298 W. Washington

Stephenville, Texas 76401

254-918-1220 Ph.

254-918-1207 Fax

Page 5 of 6

Provider Classification:

Electric Co. Gas Co.

Telephone Co. Cable Co.

Franchised or Licensed Company:

Certificated Telecommunications Provider:

Contact Name:

Address:

City: State: Zip Code:

Phone Number: Other Number:

List names of sub-contractors typically performing work in the City of Stephenville:

Name:

Address:

City: State:

Zip:

Phone Number:

Name:

Address:

City: State:

Zip:

Phone Number:

Name:

Address:

City: State:

Zip:

Phone Number:

(Use back if more space is needed)

Signed: Date:

Printed:

298 W. Washington

Stephenville, Texas 76401

254-918-1220 Ph.

254-918-1207 Fax

Page 6 of 6

Public Provider Registration Form for Public Rights-Of-Way Access

Authorized Agent of Provider

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