Fillable Right-of-Way Encroachment Or Use Permit

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Right-of-Way Encroachment Or Use Permit

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U.S.A. forms for City of Helena

BROWSE CITY OF HELENA (MT) FORMS

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updated 6/9/16
City of Helena
P
ublic Works Department
Application for Right-of-Way Encroachment or Use Permit
Applicant (please print full name):
Address:
City, State, Zip Code:
Phone Number:
Property Owner/User (please print full name):
Address:
City, State, Zip Code:
Phone Number:
REQUESTING:
7-13-3 Encroachment Permit (grant
ed by the City Manager)
7-13-4 Non-Exclusive Right-of-Way Use Permit – duration of permit may not exceed 5 years (grant
ed by the City Manager)
7-13-5 Exclusive Right-of-Way Use Permit (a private use that does not allow public access through the right-of-way) (grant
ed by the
City Commission)
Street address of property:
Legal Description of property:
Type, name, and legal description of Right-of-Way to be utilized (street, sidewalk or alley):
Purpose for Right-of-Way Use (including description of encroachment/use and duration of use):
Site Plan (must include drawing of the location and dimensions of the right of way area proposed for the encroachment and the
arrangement of objects, fixtures, or portions of structures expected to be located in the right of way.) For further detail information attach
additional sheets
Certificate of Liability Insurance (for Exclusive Right-of-Way Use Permits only)
NOTE TO APPLICANT
- Owner must provide a signed application, site plan, and any maps for review by f the City of Helena Public Works Department.
- Exclusive Right-of-Way Use: There is an annual fee of 5% of the market value or a minimum of $50.00 for all Exclusive
Right-of-Way Use permits and must be approved by the City Commission.
- The applicant for an exclusive right of way use permit shall indemnify, defend, and hold the city and its employees and agents
harmless against all claims, liability, loss, damage, or expense incurred by the city due to any injury to or death of any person
or any damage to property caused by or resulting from the activities for which the permit is granted. As evidence of the
applicant's ability to perform the conditions of the permit, the applicant shall furnish a policy or certificate for comprehensive
general
liability insurance with the city named as an additional insured. Such certificate of insurance shall be in the amount of
one million dollars ($1,000,000.00) per claim or occurrence.
______________________________________
P
rinted Name of Owner/User
______________________________________ ________________________________________________________
Signature Owner/User Date:
Date Received Process By:
316 N Park Ave
Helena, MT 59623
Phone: 406-447-8431
FAX: 406-447-8442
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Right-of-Way Encroachment Or Use Permit

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Completed 12 July 2020

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