Full Text
CITY OF MIDLAND APPLICATION FOR UTILITY PERMIT Part I Date: Street(s): To: APPLICANT: Contact Person: Address: Title: Contact Telephone Contact Mobile Fax Est. Commence Date Est. Completion Date Contact E-mail Signature, Title (Print Name, Title) PROPOSED CONSTRUCTION METHOD: Trench , Bore , Aerial , Other Description of Work: CLEARANCE FROM CITY UTILITIES: (Provide Location and Minimum Clearance from City Utilities), Water (Min. 10’ Horiz., 2’ Vert.) Sanitary (Min. 5’ Horiz., 1’ Vert.) Storm (Min. 5’ Horiz., 1’ Vert.) DEPTHS: Avg. Prop. Utility Depth Range of Depth to [Provide Attachment if Needed] CLASS OF WORK: TRAFFIC IMPACTS: A [ ] New underground facilities (cable, conduit) [ ] Major Street [ ] New underground services-roadway excavation [ ] Closing Required [ ] Closing of Parking Lane B [ ] New aerial facilities-new poles [ ] Closing of Traffic Lane [ ] New aerial facilities-existing poles [ ] Affect Sidewalk C [ ] New underground service-no roadway excavation D [ ] Repair existing underground Facilities [ ] Repair/replace existing poles [ ] Replace/place cable in existing u/g facilities E [ ] New underground structures [ ] New surface structures For Office Use Only Permit No: Application No: Permit Completion Date: Part I Approval Date: Part II Approval Date: FEES: For Office Use Only Class A, B, $ Class $ Class E-Special Permit…($50) $ TOTAL $ ---PAGE BREAK--- Part II (To be completed and submitted a minimum 3 days prior to start) CONTRACTOR: Contact Person: Address: Contact Telephone Contact Mobile Contact Fax Actual Start Date: Note: Permit Completion Date is as indicated in Part I. SAFETY PLAN: City of Midland Other, Special Notes: City requires all personnel working in or utilizing City right-of-way must wear safety vests at all times and comply with MIOSHA and all other applicable safety requirements in the City Safety Manual. Other Safety Plans may be used if they are included and are equal to or more restrictive than the City Safety Manual. Restoration shall be in accordance with City of Midland standard specifications. Notify affected residents prior to beginning work. Remove Miss Dig Flags when work is completed. TRAFFIC CONTROL PLAN (if applicable): Michigan Manual of Uniform Traffic Control Devices (MMUTCD), Attach or name specific sections. Other, Attach drawings and descriptions for review and approval by the City. For Office Use Only SPECIALCONDITIONS APPROVALS: Engineering: Office Water Distribution: Waste Water Department: Parks Department: Dept. of Public Services: Other: Part II Title: Date: COMMENTS AND RESTRICTIONS: Actual Completion Date: As-Built (Up to 30 days after completion) Yes, No As-Built Submittal Date: Notes: