Fillable RIGHT-OF-WAY PERMIT APPLICATION (Town of Ashland, VA)

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RIGHT-OF-WAY PERMIT APPLICATION (Town of Ashland, VA)

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BROWSE TOWN OF ASHLAND, VA (VA) FORMS

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Revised 12/2020
RIGHT-OF-WAY PERMIT APPLICATION
Effective Date: Permit Number
Expiration Date:
APPLICATION is hereby made for permit as shown on the accompanying plan or sketch and as described below. Said activity(s) will be done under and in accordance with the
rules and regulations of the Town of Ashland, in so far as said rules are applicable thereto and any agreement between the parties herein before referred to. Where
applicable agreements may be attached and made a part of the permit assembly including any cost responsibilities covering work under permit. Applicant agrees to
maintain work in a manner as approved upon its completion. Applicant also hereby agrees and is bound and held responsible to the owner for any and all damages to
any other installations already in place as a result of work covered by resulting permit. Applicants to whom permits are issued shall at all times indemnify and save
harmless the Town of Ashland, and all Town of Ashland employees, agents, and offices, from responsibility, damage, or liability arising from the exercise of the privileges
granted in such permit to the extent allowed by law. In consideration of the issuance of a permit the applicant agrees to waive for itself, successors in interest or assigns
any entitlements it may otherwise have or have hereafter under the Uniform Relocation and Assistant Act of 1972 as amended in event the Town of Ashland, chooses
to exercise its acknowledged right to demand or cause the removal of any or all fixtures, personality of whatever kind or description that may hereafter be located,
should this application be approved.
Request permission
to perform the following:
Location: GPIN Number Address or Street
1
st
Cross Street 2
nd
Cross Street
Signature of applicant Date
Printed Name / Title
Attachments:
Fee ($100) Bond - Amount: Plans
Agreements Special Instructions Regulation Forms
TOWN OF ASHLAND
Permission is hereby given insofar as the Town of Ashland has the right, power, and authority under Sections 33.1-12 (3); 33-1-197; 33-1-198 and
9-6.1 of the Code of Virginia (1950) as amended and the Ashland Town Code, to grant by special agreement and/or by permit for you to perform
the work and or activity(ies) described above, applicable as are stated within the Ashland Town Code and/or as per approved plan(s) and/or
regulatory instructions and/or agreements attached hereto.
BY: TITLE:
Director of Public Works
Applicant:
Owner Agent Driver’s license or Tax ID number
Contact Name
Name E-mail Address
Address Phone Number
City/State/Zip Emergency Number
Other:
Owner Agent Driver’s license or Tax ID number
Contact Name
Name E-mail Address
Address Phone Number
City/State/Zip Emergency Number
click to sign
signature
click to edit
Town of Ashland TOA-LUP-SP
Department of Public Works RIGHT OF WAY PERMIT
5/2009 Special Provisions
NOTICE OF PERMITTEE LIABILITY
Permittee Agreement for Right-of-Way Permit
I the undersigned Permittee/Agent, acknowledge that I have read and I am fully cognizant of all of the following
requirements for permit issuance.
P
ermittee Name ________________________________________________________________
Permittee
Signature___________________________________________________________Date_______________________
A
ny of the following provisions, which can apply, shall apply:
1. P
ermittee acceptance and use of a Town of Ashland (Town) Right-of-Way Permit is prima facie evidence that th
e
P
ermittee has read and is fully cognizant of all required permit provisions, applicable traffic control plans and associated
construction standards to be employed. ALL applicants to whom permits are issued shall at all times indemnify and
save harmless the Town Council, members of the Council, the Town, and all town employees, agents, and officers, from
responsibility, damage, or liability arising from the exercise of the privileges granted in such permit to the extent allowed
by law.
2. T
he Permittee agrees to secure and carry insurance against liability for personal injury and property damage that may
arise from the work performed under permit and/or from the operation of permitted activity-up to one million dollars ($
1,000,000) each occurrence to protect the Council Members and Town’s agents or employees; seventy-five thousand
dollars ($75,000) each occurrence to protect the Council, or the Town in event of suit.
3. T
he Permittee assumes full responsibility for any and all damages (e.g., downstream flooding, erosion, siltation, etc.) tha
t
m
ay occur as a result of the work performed under this permit. Furthermore, the Town will in no way be responsible for
any damage to the facility being placed as a result of future maintenance or construction activities performed by the
T
own.
4. T
he Permittee agrees to move, remove, alter, or change any installation that interferes with the ultimate construction of
the roadway in alignment or grade
without cost to the Town unless otherwise stipulated and agreed to by the Town.
5. T
he Permittee shall immediately have corrected any situation which may arise as a result of these installations that th
e
D
irector of Public Works or his/her representative deems hazardous to the traveling public.
6. A
ny and all roadway signs, Right-of-Way markers, etc., disturbed as a result of work performed under this permit shall
be accurately reset by the Permittee immediately following the work in the vicinity of the disturbed facility. The services
of a certified land surveyor with experience in route surveying may be required.
7. I
t shall be the Permittee's responsibility to obtain ANY and ALL necessary permits that may be required by any other
government agencies, e.g., Corp. of Engineers, Dept. of Environmental Quality, Soil Conservation Services, etc.
8. A
copy of the permit shall be kept on-site at all times.
9. T
he Permittee is required to notify the Department of Public Works at
least 48 hours in advance of ANY proposed work
c
ommencing.
10. T
he Permittee is required to notify the Department of Public Works when planned excavation is within 1,000 feet in the
vicinity of a signalized intersection. Failure to carry out this requirement may result in the permit being revoked.
11. The Permittee must possess a “cleared” utility ticket from “Miss Utility of Virginia” prior to beginning any excavation
a
ctivities under this permit. Failure to carry out this requirement may result in this permit being revoked.
12. T
he Town will assign an Inspector to the project.
TOA-LUP-SP
Right Of Way Permit
Special Provisions
Page 2 of 4
13. The absence of an Inspector does NOT in any way relieve the Permittee of his/her responsibility to perform the work in
accordance with the approved plans and provisions of the attached permit and the VDOT Road and Bridge Standards
(current edition), the VDOT Road and Bridge Specifications (current edition), and the Town of Ashland Code. No
changes shall be made without approval of the Director or Public Works or his/her representative.
14. It is the duty of the Director of Public Works or his/her representative to keep all roadways maintained in a safe,
travelable condition at ALL times. Therefore, any permit may be denied, revoked or suspended, when in the opinion
of the Director of Public Works or his/her representative, the safety, use or maintenance of the roadway so requires.
15. The Permittee shall at ALL times give strict attention to the safety and rights of the traveling public, her/his employees
and herself/himself. The Town
reserves the right to stop work at anytime due to safety problems and/or
noncompliance with the terms of the permit. The Town may, at its discretion, complete any of the work covered in the
permit or restore the Right-of-Way to Town’s standards and bill the Permittee for the actual cost of such work. The
Permittee may be required to move, alter, change or remove from the Town’s Right-of-Way, in a satisfactory manner,
any installation made on the Right-of-Way under this permit.
16. All work performed under this permit on the Town’s Right-of-Way shall be subject to the Town’s direction, and shall be
in accordance the VDOT Road and Bridge Standards (current edition), the VDOT Road and Bridge Specifications
(current edition) and the Town of Ashland Code, and shall be performed to the satisfaction of the Director of Public
Works or his/her representative.
17. Design changes, specified material changes and/or field changes from the approved plans need to be submitted to the
Department of Public Works prior to proceeding with the work. A letter of explanation shall accompany the revised
design plans and/or engineering calculations, which must be submitted to the Town for review and approval by the
Department of Public Works.
18. The permittee shall meet or exceed the existing pavement and sub-base typical section when constructing pavement
widening adjacent to an existing Town maintained roadway. The proposed typical section must be reviewed and
approved by the Director of Public Works or his/her representative prior to commencing with any work within Town
maintained right-of-way. ALL pavement widening shall be in accordance with VDOT Road and Bridge Standard
303.02 and Town requirements.
Traffic Control and Safety Procedures:
19. Traffic shall NOT be blocked or re-routed (detoured) without written permission from the Director of Public Works or
his/her representative. Where one-way traffic is permitted to be maintained, it shall be properly flagged 24 hours per day
by a trained, certified flagperson. A certification card is required for any person flagging within the Town’s Right-of-
Way.
20. During construction, the Permittee shall furnish ALL necessary signs, flagpersons and other protective devices (lights,
barricades, etc.) for protection of traffic and workers in accordance with the specifications of the Virginia Work Area
Protection Manual or as directed by the Director of Public Works or his/her representative. All signs shall be in
accordance with the current edition of the Manual of Uniform Traffic Control Devices (MUTCD). Trained, certified
flagpersons shall be provided in sufficient number and locations as necessary for control and protection of vehicular and
pedestrian traffic in accordance with MUTCD. Flagpersons shall use sign paddles to regulate traffic in accordance with
MUTCD.
21. Certification card shall be carried by the flagperson while performing duties. A flagperson found not in possession of
his/her certification card shall be removed from the flagging site and the Director of Public Works or his/her
representative will suspend operations requiring flagpersons. Furthermore, flagpersons performing duties improperly
shall have their certification revoked.
22. No excavated material is to be placed or tracked on the pavement, without written permission of the Director of Public
Works or his/her representative. When so permitted, the pavement shall be satisfactorily cleaned by an approved
method. No cleated (track-mounted) equipment is to be used on the pavement, without proper protection to the
pavement.
TOA-LUP-SP
Right Of Way Permit
Special Provisions
Page 3 of 4
Hours and Days of Work
23. Permittee is authorized to perform work that involves lane closures and/or impede/stop traffic only between the hours of
9:00 a.m. to 3:30 p.m. Monday through Friday. The permit will not be valid from 12:00 noon on the weekday preceding
and through the following holidays: New Year’s Day; Memorial Day; Independence Day; Labor Day; Thanksgiving
Day; Christmas Day. If the observed holiday falls on Monday, the permit will not be valid from 12:00 noon on the
preceding Friday through the holiday. Additional restrictions on allowable work hours may apply depending on
location, time of year, or other factors. Any variance in times of work must be obtained from the Director of Public
Works or his/her representative.
Excavations:
24. OSHA requires shoring for any excavation four feet (4’) or more in depth.
25. When not utilizing shoring, excavations are to be sloped accordingly.
26. A licensed Professional Engineer shall certify all shoring and/or trenching boxes.
Inspection and Restoration
27. Inspection and testing of all fill embankments, storm sewer and utility trench backfill shall be performed in
accordance with all applicable sections of VDOT’s Road and Bridge Specifications (current edition).
28. A licensed geotechnical engineer (or certified technician under the direction of a licensed geotechnical engineer) shall
observe the placement of all fill embankments, and storm sewer and utility trench backfill.
29. The permittee may retain services of licensed geotechnical engineer (or technician under the direction of a geotechnical
engineer) to perform required inspection and testing, or,
30. All testing reports and engineer's certification shall be submitted to the Town for review and approval prior to
completion of the Right-of-Way Permit.
31. The permittee shall be responsible for correcting any settlement of backfill or pavement for a period of three (3) years
after completion of work.
32. Where pavement exists, all crossings shall be bored, pushed or jacked from back-of-ditchline to back-of-ditchline or toe-
of-fill to toe-of-fill. The pavement shall NOT be cut unless otherwise approved by the Director of Public Works or
his/her representative and then only if justifiable circumstances prevail or proof is shown that a thorough attempt has
been made to push, bore or jack.
33. Whenever the pavement is permitted to be cut, not over one-half of the roadway width shall be disturbed at one time; the
first opening shall be completely restored to satisfactory, travelable condition before the second half can be opened. The
permittee shall mill and resurface ALL (asphalt) concrete roadways; and resurface all other roadway with like material
that exists. Whenever the pavement is permitted to be cut, the provisions of LUP-OC shall apply. Where the pavement
is disturbed or deemed weakened in its entirety or such portions as deemed desirable by the Town, the pavement shall be
restored or replaced in a manner that is satisfactory to the Director of Public Works or his/her representative. The
“Pavement Patching Detail for small openings” shall apply for cuts 2’ x 2’ or smaller (e.g., potholes for utility location).
Environmental
34. The permittee is responsible for pursuing and obtaining any and all environmental permits which may be required to
pursue the proposed activity prior to any work beginning within Town right of way.
35. In the event the permittee encounters hazardous materials or underground storage tanks within the right of way in the
pursuit of his activities, the permittee is responsible for ceasing all work within the site and notifying the Town and other
responsible groups, i.e. local fire department, emergency services, Virginia Department of Environmental Quality, etc.
The applicant is responsible for coordinating and completing all remedial/removal activities required in order to properly
complete the proposed activities within the Town right of way.
36. In the event the permittee encounters cultural resources, archaeological, paleontological, and rare minerals, within the
right of way in the pursuit of his activities, the applicant shall act immediately to suspend work at the site of the
discovery and notify the Town. The permittee is responsible for notifying the proper state authority charged with the
TOA-LUP-SP
Right Of Way Permit
Special Provisions
Page 4 of 4
responsibility for investigating and evaluating such finds. The permittee will meet all necessary requirements for
resolving any conflicts prior to continuing with the proposed activities within the Town right of way and shall provide
evidence of such compliance to the Town.
37. Roadway drainage shall NOT be blocked or diverted. The shoulders, ditches, roadside and drainage facilities, as well as
the pavement, shall be kept in an operable condition satisfactory to the Town. Necessary precautions shall be taken by
the permittee to insure against siltation of adjacent properties, streams, etc., in accordance with State Law and the Town
Code.
Entrances
38. Road and street connections, private entrances, and construction entrances are to be kept in satisfactory condition.
Entrances shall NOT be blocked. Ample provision must be made for safe ingress and egress to adjacent property at all
times. Where entrances are disturbed they shall be restored to the satisfaction of the property owner and the Director of
Public Works or his/her representative
39. The permittee is responsible for determining the correct size of each entrance pipe through the submittal of engineering
calculations to the Town for review and approval.
Utilities
40. Prior to any excavation, the permittee shall comply with the terms of Title 56, Chapter 10.3 of the Underground Utility
Damage Prevention Act and Section 56-265.14 through 56-265.20 of the Code of Virginia. This permit does NOT
grant permission to grade on or near property of others, or, adjust or disturb in any way existing utility poles or
underground facilities within the permitted area. Permission to do so must be obtained from the impacted utility
company and any expense involved shall be borne by the permittee.
Any conflicts with existing utility facilities must
be resolved between the permittee and the utility owner(s) involved.
41. All underground utility crossings and parallel installations shall have a minimum cover of 36 inches except underground
telecommunications cables placed adjacent to the outside edge of the right-of-way line and beyond of ditch line shall
have a minimum of 30 inches cover. All other underground facilities shall have a minimum cover of 36 inches.
42. Where feasible, all aboveground installations (such as fire hydrants, telephone pedestals, markers, etc.) shall be located
adjacent to the outside edge of the right-of-way line and in accordance with minimum clear zone requirements. Tops of
all manhole covers, valve boxes, etc., in paved areas or shoulders shall be at finished grade and shall conform to road
grades. Tops of all manhole covers, valve boxes, etc., outside paved areas shall be in accordance with Hanover County
Water & Sanitary Sewer Standards.
43. No poles, guys, anchors, etc., are to be placed in Town maintained right-of-way unless so indicated and approved on this
permit. At no time will any such facilities be allowed between the ditch line and the traveled roadway.
44. ALL overhead crossing(s) shall conform to the requirements of the National Electrical Safety Code (current edition).
The vertical clearance of the lowest wire or cable crossing shall not be less than 18 feet for crossing all primary and
secondary roads, and entrances.
Final Inspection and Completion of Permit
45. Upon completion of the work covered by this permit, all disturbed areas outside of the roadway prism shall be restored to
their original condition as found prior to starting such work.
46. Completion of this permit is contingent upon the permittee’s compliance with ALL governing bodies involved in the
total completion of work on Town maintained right-of-way.
47. The permittee is required to notify the Town upon completion of work covered by the attached Right of Way Permit to
request a final inspection.
Pavement Patching Detail
Notes:
• All pavement markings damaged or destroyed by trench excavation activity shall be replaced by the
permittee in accordance with current VDOT Standards & Specifications
• This detail applies to roadways with existing asphalt pavement sections
• The extent of pavement restoration for all other pavement types shall be determined by the Director
of Public Works or his/her designee.
* Width of travel lane; minimum full pavement width restoration for open cut trenching along the road
centerline or for perpendicular crossing as follows (or as determined by Director of Public Works or his/her
designee):
• Local and residential road – 10’ minimum
• Collectors and arterials – 25’ minimum
May 12, 2014
S:\PUBWKS\Forms\PavementPatchingDetail.pdf
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RIGHT-OF-WAY PERMIT APPLICATION (Town of Ashland, VA)

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Completed 14 January 2021

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