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EXCAVATION RIGHT OF WAY PERMIT APPLICATION City of Douglas PO Box 1030 Douglas, WY 82633 Date: Permit Business Name: Business Address: City: State: Zip: Contact Person: Phone: Property Owner: Location of Proposed Work: Description of Proposed Work: Notified One Call: Size of Proposed Cut: Map Attached (Required): Proposed Starting Date: Estimated Completion Date: Estimated Project Cost: $ Traffic Control Required: Dates: (if yes, please indicate on map) Project cost less than $10,000: By signing below, I hereby agree to liquidated damages for any delay over the stated or amended completion date in the amount of one hundred fifty dollars ($150.00) per day if cut is under three hundred (300) feet in length, three hundred dollars ($300.00) per day if between three hundred (300) and five hundred (500) feet, and five hundred dollars ($500.00) per day if over five hundred (500) feet in length. Permit Fee - $30, $60 if application is submitted after work has begun, except in case of emergencies. Applicant Signature Date By signing this application, I hereby agree to be bound by the provisions of all ordinances, specifications, and regulations of the City of Douglas; to restore the area of work to the original condition; and to comply with all special conditions, restrictions, and regulations imposed by the Public Works Director or designee per Section 12.04.090 of Douglas Municipal Code. I further hereby acknowledge that any person or organization who is issued a permit hereunder, shall by operation of the issuance of the permit, indemnify and hold the City, its employees, agents and representatives, including members of the City Council in their representative capacities, harmless from any liability, loss or damage which may be incurred as a result of claims, demands, costs, or judgments arising out of, connected with, or concerning the issuance, use or existence of the permit. Applicant Signature Date SIGN SIGN ---PAGE BREAK--- EXCAVATION RIGHT OF WAY PERMIT APPLICATION City of Douglas PO Box 1030 Douglas, WY 82633 TO BE COMPLETED BY THE CITY OF DOUGLAS - DO NOT WRITE BELOW THIS LINE ADMINISTRATIVE SERVICES DEPARTMENT: Receipt Receipt Date: Surety Bond Required: Yes No (Project Cost Estimate Greater than $10,000) Surety Bond Received: Yes No BY: Approved: Yes No BY: Date: COMMUNITY DEVELOPMENT DEPARTMENT: Building Permit Required: Yes No Issued: Yes No Permit Contractor’s License Required: Yes No Issued: Yes No License Approved: Yes No BY: Date: PUBLIC WORKS DEPARTMENT: Utilities Notified: Yes No Locate # Application Approved: BY: Date: Application Denied: BY: Date: Required Completion Date: Reason: Remarks: Remarks PERMIT ISSUED: DATE: INSPECTION RECORD: Item Approved Disapproved Initials Date Asphalt Cut/Replace Backfill Compaction Patch Clean Up Completion Accepted: BY: Date: Completion Not Accepted: BY: Date: Surety Bond Release Approved: BY: Date: Completion Requirements: Surety Bond Released: BY: Date Liquidated Damages Start: Liquidated Damages End: