Fillable TOWN OF ACTON APPLICATION FOR PERMIT TO CONSTRUCT (Town of Acton, Massachusetts)

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TOWN OF ACTON APPLICATION FOR PERMIT TO CONSTRUCT (Town of Acton, Massachusetts)

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BROWSE TOWN OF ACTON, MASSACHUSETTS (MA) FORMS

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Date:……………………………….. Permit No……………..……
TOWN OF ACTON
APPLICATION FOR PERMIT TO CONSTRUCT WITHIN A PUBLIC WAY
This application must be submitted not less than five (5) days prior to any Construction within a
public way.
Notice 24 hours in advance of any construction must be given to the Town Engineer.
1. Applicant/Licensee:_______________________________Address:_________________________________________
1A. Telephone #: Email Address: ________________________________________
2. Location of Proposed Construction:
3. Purpose of Construction:
License Category (choose one) – see Rules & Regs for details:
1- New Driveway 2 -Minor Construction 3-Major Construction 4-Public Utility 5-Winter Construction
4. Length of Cut: (feet). Width of Cut: (feet). Total Area: _________(sq.ft)
6. Width of Existing Pavement: (feet)
7. Type of Existing Roadway Surface: Type of Curb:
8. Type of Existing Sidewalk Surface: Type of Shoulder:
9. Date of Construction: From: (Expires December 15
th
; Work must commence within 90 days)
For Work involving Excavations 10. Dig Safe Number:
11. Drain Layer License #:____________________________________
12. Land Disturbance Threshold certification. The proposed construction (check all that apply):
Disturbs less than 1 acre of total area
Disturbs less than 5,000 sq.ft of 1) impervious area and 2) areas with a 10% slope or greater
Does not alter an existing stormwater drainage system serving 5,000 sq.ft of impervious area
I, the undersigned herby declare that I have Read and Agree to the Town of Acton Specifications for Regulating Construction
with Public Ways dated January 22, 2018. I have deposited the required bond with the Town of Acton and I covenant and agree that
the Town may deduct from this amount the cost of repairs to the road surface, curbs, shoulders, walls or other features within the right-
of-way including replacing bounds if not completed by me to the satisfaction of the Town Engineer within the specified time.
Signature of Applicant.
Special Instructions (Internal Use):
Year Paved:_______ Pavement PCI:________ Infrared Required? (yes/no):________
Current UC:_______ LCMC Fee:_________($) Moratorium Fee:_________($)
In Sewer District? (yes/no):______ Other Instructions:
Permit issued: Date…………..……………………………………….By:………………………………………………….
Application Denied: Date…………………………………………….By:………………………………………………….
[Type text]
Street Cut Checklist- Version 2019-01
Date:……………………………….. Permit No……………..……
TOWN OF ACTON
CHECKLIST FOR PERMITS FOR CONSTRUCTION WITHIN A PUBLIC WAY
Items to be submitted with all permit applications:
Completed Permit Application
Plan showing the proposed construction
Certificate of Insurance (see insurance requirements within rules & regulations)
W-9 Tax Identification Form – Current Year
Additional documents to be submitted:
Type 1 – New Driveways
Fee/Performance Bonds
o $75 – Application/Inspection Fee
o $1500 – Performance Guarantee (cash only)
Land Disturbance Permit (if applicable)
Type 2 – Minor Construction (Under 10 square feet of pavement disturbed)
Fee/Performance Bonds
o $100 – Application/Inspection Fee
o $5000 minimum – Performance Guarantee (cash or surety bond)
o Moratorium Fee & LCMC Fee – to be calculated by Engineering Department
Land Disturbance Permit (if applicable)
Drain Layer License
Type 3 – Major Construction (Over 10 square feet of pavement disturbed)
Fee/Performance Bonds
o $150 – Application/Inspection Fee (additional fee may be required)
o $7500 minimum – Performance Guarantee (cash or surety bond)
o Moratorium Fee & LCMC fee – to be calculated by Engineering Department
Land Disturbance Permit (if applicable)
Drain Layer License
Type 4 – Public Utility Companies (Does not apply to third party contractors) – Contact Engineering
Type 5 – Winter Construction (All work occurring between 12/15 and 3/15)
Fee/Performance Bonds
o $175 – Application/Inspection Fee (additional fee may be required)
o $7500 minimum – Performance Guarantee (cash or surety bond)
o Moratorium Fee & LCMC Fee – to be calculated by Engineering Department
Land Disturbance Permit (if applicable)
Drain Layer License
[Type text]
Street Cut Checklist- Version 2019-01
TOWN OF ACTON
LIFE CYCLE MAINTANENCE & MORATORIUM FEES
Per sections 1.1.5 & 2.1.4 of the Rules & Regulations for Permits to Construct within Public Ways and
the Acton Board of Selectmen Fee Policy adopted November 19, 2018:
Moratorium Roads & Roads with a PCI over 85
Type 4 Permittees:
o Gas Leak Repairs & Gas Main Relays – Fees Waived, full-width mill & overlay required
o New Gas Services & Main Extensions - Fees Required, Infrared or Final Patching Required
o All other public utility construction – Fees Required, Infrared or Final Patching Required
All Other Permittees (Types 2-5):
o Moratorium & LCMC Fees required
o Infrared Paving Required
o Minimum $25,000 bond required (Types 2,3+5)
Roads with a PCI of 65 to 85
Type 4 Permittees:
o Gas Leak Repairs & Gas Main Relays - LCMC Fee waived, final patch required
o New Gas Services & Main Extensions – LCMC Fee required, temporary patch required
o All other public utility construction - LCMC Fee required, temporary patch required
All Other Permittees (Types 2-5):
o LCMC Fee required
o Temporary patch required
o Minimum $7500 bond required
Roads with a PCI below 65 & Roads on Highway 5-Year Resurfacing Plan
All Permittees: LCMC Fee waived, temporary patch required
Applicants requesting fees to be waived in cases not listed shall do so in writing. The Engineering Department
reserves the right to require the fees if it is determined to be in the best interest of the Town.
Moratorium Fee: 0-1 Years: $2,500 [2019]
[Year Road Was Paved] 1-2 Years: $2,000 [2018]
2-3 Years: $1,500 [2017]
3-4 Years: $1,000 [2016]
4-5 Years: $750 [2015]
Life Cycle Maintenance Fee: (L x W x UC + $400) x PCI
L = length of trench (feet)
W = width of trench (feet)
UC = unit cost to reconstruct a roadway ($0.91/SF)
PCI = Pavement Condition Index (%) of road prior to start of construction – See GIS mapping
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TOWN OF ACTON APPLICATION FOR PERMIT TO CONSTRUCT (Town of Acton, Massachusetts)

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Completed 11 February 2021

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