UTILITY PERMIT INSTRUCTIONS

Transcription

1 STEELE COUNTY HIGHWAY DEPARTMENT UTILITY PERMIT INSTRUCTIONS REGISTRATION FORM Annual requirement for any new or existing Owner or Contractor that will perform construction or maintenance work on their facilities within or across Steele County right-of-way Submit with ANNUAL UTILITY CONSTRUCTION PERMIT form if applicable (see below) May be submitted with first UTILITY PERMIT form of each year Please note the emergency repair permission and conditions listed on page 2 of the REGISTRATION FORM Registration Fee = $30 (annually) ANNUAL UTILITY CONSTRUCTION PERMIT Covers new construction or maintenance work that is part of an Owner s annual work plan on their facilities within or across Steele County right-of-way Submittal of detailed plans is required Submit with REGISTRATION FORM Not required if Owner does not have an annual work plan within Steele County Individual UTILITY PERMITS (see below) are still required for work that is not included with the ANNUAL UTILITY CONSTRUCTION PERMIT submittal Permit approval is required prior to starting work Contact the for final inspection and acceptance after work is complete by completing the bottom of Page 1 and submitting via mail or fax, as listed on the permit. Permit Fee = $90 (annually) UTILITY PERMIT Covers individual new construction and maintenance work that was not submitted as part of an ANNUAL UTILITY CONSTRUCTION PERMIT Covers emergency repairs that are permitted with REGISTRATION (submittal of retroactive UTILITY PERMIT form must be made within two business days) Submittal of detailed plans is required Permit approval is required prior to starting work. Contact the for final inspection and acceptance after work is complete by completing the bottom of Page 1 and submitting via mail or fax, as listed on the permit. Permit Fee = $30 (each) S:\Permits\Utility Permit Instructions doc 2/4/10 STG

2 Form A Registration Fee $ Florence Ave Owatonna, MN Phone (507) Fax: (507) REGISTRATION FORM REGISTRATION TYPE Please check the following: New Applicant Updating information Please check whether you are a Utility or a Contractor wishing to work within the ROW. Utility Contractor Other: If you checked other, explain below. REGISTRANT (COMPANY) INFORMATION Name: ( ) Fax: ( ) ( ) Type of Utility: LOCAL CONTACT REPRESENTATIVE A Local Contact Person that can speak for your Company and who is authorized to accept official notices from the County and act as agent for the Registrant. Name: ( ) Fax: ( ) ( ) 24 Hour Emergency Contact Information Name Phone Fax Cell BONDS, CERTIFICATES, LICENSES, ETC. Please attach the following as required by Steele County for registration: (1) $10,000 Blanket Bond (non expiring) for emergency repairs within Steele County Right of Way. (2) Certificate of Liability Insurance. (Minimum of $1,500,000 per Occurrence & $3,000,000 General Aggregate) Received Page 1 of 2

3 Form A Registration Fee $30.00 By submitting this document, the registrant is granted permission to perform emergency repairs to existing facilities, subject to the following conditions: 1. The registrant shall immediately notify the, via phone or , of any events regarding its facilities that require emergency repairs. During non-business hours, a voice message is an acceptable form of notification. 2. Within two (2) business days of the occurrence of the emergency repair, the registrant shall apply for the necessary permits, pay the fees associated therewith and fulfill the requirements necessary to comply with said permit. County Contact/Notification (507) Fax: (507) anita.benson@co.steele.mn.us Registrant s Signature: Date: Printed Name: Page 2 of 2

4 Form B Registration Fee: $ Florence Ave Owatonna, MN Phone (507) Fax: (507) ANNUAL UTILITY CONSTRUCTION PERMIT Application is hereby made for permission to place, excavate, or obstruct within the right-of-way for the purpose of construction of (along or across) Steele County Highway right-of-way in accordance with annual construction design plans supplied to Steele County Highway Department by the Permittee with annual registration. Applicant: Contractor: 24 Hour Contact: 24 Hour TYPE OF UTILITY Gas Electrical Telecom Cable Water Sewer Other (explain) PURPOSE OF CONSTRUCTION Refer to construction plans submitted with annual registration. TYPE OF CONSTRUCTION WORK Refer to construction plans submitted with annual registration. PORTION OF RIGHT OF WAY BEING USED Refer to construction plans submitted with annual registration Roadway Shoulder Inslope Ditch Bottom Backslope Sidewalk Boulevard Other (explain) CONSTRUCTION SCHEDULE Refer to construction plans submitted with annual registration. Applicant s Signature: Date: Actual Number of Construction Days: Date Work Completed: Actual Construction Dates: Page 1 of 2

5 Form B Registration Fee: $90.00 STEELE COUNTY DEPARTMENT OF HIGHWAYS ANNUAL UTILITY PERMIT Project CSAH CR In accordance with the application herein, an Annual Utility Permit is granted to to place, construct and thereafter maintain on or across, or under the right-of-way of Steele County Highway No. in the location shown on the sketch which is a part of said application, or in such locations as may be specified by the in the Special Provisions hereof. SPECIAL PROVISIONS: Notify the (507) a minimum of 48 hrs before start of work. After work is completed notify the for final inspection and acceptance. Finish shaping and turf establishment shall begin immediately after completion of project permitted with in this utility permit. Finish shaping of all disturbed soils shall include, turf establishment, consisting of black dirt (top soil) seeding and mulching. Traffic control measures shall be in place in conformance with the most current edition of the MN MUTCD. Steele County Board of Commissioners, Steele County, Minnesota Approved: By: Date Authorized Signature Page 2 of 2

6 Form C Permit Fee: $ Florence Ave Owatonna, MN Phone (507) Fax: (507) UTILITY PERMIT Application is hereby made for permission to place, excavate, or obstruct within the right-of-way for the purpose of construction of (along or across) Steele County Highway No. from to in accordance with the attached sketch. Applicant: Contractor: 24 Hour Contact: 24 Hour TYPE OF UTILITY Gas Electrical Telecom Cable Water Sewer Other (explain) PURPOSE OF CONSTRUCTION New Replacement Repair Other (explain) TYPE OF CONSTRUCTION WORK Trench Hole Chamber Boring Pole Other (explain) PORTION OF RIGHT OF WAY BEING USED Roadway Shoulder Inslope Ditch Bottom Backslope Sidewalk Boulevard Other (explain) CONSTRUCTION SCHEDULE Number of Construction Days Applicant s Signature: Construction Dates Date: Actual Number of Construction Days: Date Work Completed: Actual Construction Dates: Page 1 of 2

7 Form C Permit Fee: $30.00 STEELE COUNTY DEPARTMENT OF HIGHWAYS UTILITY PERMIT Project CSAH CR In accordance with the application herein, a Utility Permit is granted to to place, construct and thereafter maintain on or across, or under the right-of-way of Steele County Highway No. in the location shown on the sketch which is a part of said application, or in such locations as may be specified by the in the Special Provisions hereof. SPECIAL PROVISIONS: Notify the (507) a minimum of 48 hrs before start of work. After work is completed notify the for final inspection and acceptance. Finish shaping and turf establishment shall begin immediately after completion of project permitted with in this utility permit. Finish shaping of all disturbed soils shall include, turf establishment, consisting of black dirt (top soil) seeding and mulching. Traffic control measures shall be in place in conformance with the most current edition of the MN MUTCD. Steele County Board of Commissioners, Steele County, Minnesota Approved: By: Date Authorized Signature Page 2 of 2