City of Rockford, Illinois
Public Works Department
Engineering Division
425 East State Street, Rockford, IL 61104
Phone: 779-348-7174 Fax: (815) 967-7058
Web: www.rockfordil.gov
RIGHT-OF-WAY PERMIT APPLICATION
(Permit applies, but is not limited to, the following activities within the City right-of-way: tunnel, bore, excavate, dig, lane closures, sidewalk closures, etc.)
/ / PERMIT FEE: $45.00
(DATE OF APPLICATION) (FEE WAIVED FOR PUBLIC UTILITES)
ADDITIONAL FEES FOR UNDERGROUND BORING ONLY:
0-100 FEET – NO CHARGE
101-499 FEET - $25.00 ADDITIONAL FEE
500 AND OVER - $55.00 ADDITIONAL FEE
(APPLICANT NAME – PLEASE PRINT) (IF BUILT BY A CONTRACTOR GIVE NAME & ATTACH PROOF OF BOND AND
INSURANCE)
☐
UTILITY
☐
CONTRACTOR
☐
CONSULTANT
☐
PROPERTY OWNER
(APPLICANT IS – CHECK ONE BOX) (CONTRACTOR ADDRESS – PLEASE PRINT)
(APPLICANT ADDRESS) (ADDRESS)
(PHONE) (FAX) (PHONE) (FAX)
(DESCRIPTION OF WORK – EXAMPLES: BURY 125’OF 4” GAS MAIN; ACCESS MANHOLE; INSTALL SEWER/WATER SERVICE; LANE CLOSURE; ETC.)
(LOCATION OF WORK – STREET NUMBER & STREET NAME)
☐ PAVEMENT ☐ ALLEY ☐ SIDEWALK ☐ TERRACE ☐ CURB
(WORK IS LOCATED BETWEEN THESE TWO CROSS STREETS)
IF IN PAVEMENT WHAT TYPE:
☐
CONCRETE
☐
ASPHALT
☐
BRICK
THRU a.m. p.m.
ARE ANY PAVEMENT CUTS REQUIRED?
☐
YES
☐
NO
(REQUESTED DATES FOR WORK) (WORK HOURS)
IF YES IS LOCATION ON 5 YEAR ROAD MORATORIUM?
☐
YES
☐
NO
(NOTE: IF PAVEMENT CUT IS AUTHORIZED AT LOCATION LISTED ON 5 YEAR ROAD MORATORIUM, FULL LANE RESTORATION WILL BE REQUIRED.)
The above applicant requests permission to excavate and/or occupy the public right-of-way in the City of Rockford and agrees to indemnify, hold harmless, and defend the
City of Rockford, its officers, agents, and employees, from any and all claims resulting from injuries, including
de
ath, damages or losses, including, but not limited to the
general public, which may arise or which may be alleged to have arisen out of, or in connection with such excavation and occupancy. I hereby agree to perform the work in
accordance with the provisions, specifications and requirements of all of the following:
Chapter 26, as revised, of the City of Rockford, Code of Ordinance.
IDOT’s Standard Specifications for Road and Bridge Construction, as revised.
The Standard Specifications for Water and Sewer Construction in Illinois, as revised.
Traffic control shall always be provided by the applicant or contractor and will be in accordance with the Illinois Manual on Uniform Traffic Control Devices for Streets and
Highways, as revised. A traffic control plan and standard details may be required based on the Engineer’s or designee’s discretion. 48 hours notice is required for
closures.
Accessibility requirements shall be in accordance with the Illinois Accessibility Code and a current IDOT Standard shall be submitted with the application when applicable.
Erosion & sediment control shall be in accordance with all requirements set forth in the current revision of the General NPDES Permit No. ILR10. Stabilization measures must
be initiated within seven (7) days after construction activities have temporarily or permanently ceased.
All other federal, state, and local requirements as they may apply.
THE FOLLOWING ITEMS ARE TO BE SUBMITTED WITH THE
APPLICATION:
CERTIFICATE OF INSURANCE - $3,000,000 per occurrence, City of Rockford listed as additional insured, and valid through the permit period.
CERTIFICATE OF BOND - $50,000 limit, acceptable forms are Right-of-Way and License & Permit, City of Rockford listed as Obligee, and valid through the permit period.
PROJECT DESCRIPTION – including site plan / drawings and schedule for all activities taking place in the public
right
-of-way including dimensions of pavement cuts.
TRAFFIC CONTROL PLAN – Any closure of streets or sidewalks shall require a traffic control plan to be submitted.
(AUTHORIZED REPRESENTATIVE SIGNATURE) (AUTHORIZED REPRESENTATIVE PRINTED NAME)
FOR INTERNAL USE ONLY
APPROVED BY: START DATE:
/ /
EXPIRES:
/ /
APPROVAL
DATE:
/ /
PERMIT FEE: PERMIT
#:
(PAY CODE -
10101000-61403)
***J.U.L.I.E. locates that take place in newly constructed areas, in the downtown districts or on specialty surfaces (ie. decorative brick, brick pavers, etc.) will need to be done
in a manner where they do not leave lasting marks on the surface. SPRAYPAINT WILL NOT BE USED. The applicant of the permit will be responsible for removal of any
marks or damages done to these surfaces.***
Rev.
(12/28/2018)
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