City of Adrian
135 e. maumee street Adrian, Michigan 49221
p: 517-263-2161 f: 517-264-8016 cityhall@adrianmi.gov
adriancity.com
Right of Way/ closure application
Nature of Work/ Closure:
Detailed Description of
Area of Work/ Closures:
Work/Closure to Begin: __________________________ Work/Closure to End: _____________________
Additional Information
Needed
Supplied
Diagram (including dimensions) for area to be enclosed to show placement of tents, carts, etc.
Certificate of Liability Insurance
Hold Harmless Agreement
Traffic Management Plan
Name: ____________________________________________________________________________________
Daytime Phone: ___________________________ Cell Phone: ___________________________________
Address: __________________________________________________________________________________
City: ________________________________State: __________________ Zip: _________________________
Email: _____________________________________________________ Fax: _________________________
Contractor Name:___________________________________________________________________________
Contractor Phone:___________________________________________________________________________
Construction Plan & Fees
Type of Work
Paid
$40.00
$500.00 Deposit
$30.00
$100.00
$50.00
$500.00 Deposit
$150.00
Base Permit fee
Dig in ROW within Pavement
Concrete Work/ Excavation within ROW
Hang a Banner
Storm Sewer Tap
Directional Boring
Permit Pulled After Work has Started
Street or Parking Lot Closure $75.00
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Needed
Parks & Engineering
DPW
Forestry
Utilities
Police Chief
Fire Chief
Administrator
Approvals
______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
Date
_________________
_________________
_________________
_________________
_________________
_________________
_________________
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Supplemental Specifications
The applicant shall allow the City Engineer or his representative on the site at all times to inspect the work.
If an inspector is needed to stay with the work, the cost of the inspection will be paid by the applicant. Failure topay
inspection costs becomes a single lot assessment.
All work shall be performed to MIOSHA rules and regulations. Trench protection and shoring shall be theresponsibility of
the contractor and owner.
All excavated material shall be stored off the right-of-way or removed promptly if excavated from the travelportion of the
street. Back fill material shall not be stored in a way to impede the flow of storm water, or within10 feet of any tree.
Approved back fill:
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under the tree the distance required. No looping around a tree shall be allowed. Exceptions to these boring requirements
must be approved by the City Forester before the permit is issued.
This permit application covers only the work anticipated. Any additional work requires modification to the permit. The work is subject
to the following condition:
1. All work is to be performed at no cost to the City of Adrian.
2. Owner accepts responsibility for the work. Any work performed by the City to secure or finish the work shall become a single
lot assessment to the applicant’s property.
3. Contractor and owners are responsible for all necessary precautions to prevent injury or damage to persons or
property.
4. Provide and maintain all traffic control devices stipulated in either:
a. Owners supplied traffic management plan
b. The City mandated traffic management plan. No signs will be provided by the City unless the street/
parking lot box is checked.
5. Proof of insurance and restoration bond shall either be provided by the applicant or be on file with the City.
6. Contractor or owner to call MISS DIG prior to commencement of any work.
7. Permit to close any street/ parking lot requires additional approval from the City Administrator.
8. Utility work, water and/or sewer, require separate permitting and inspection through the City Utilities Department.
Signature
Special Comments
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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