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1. Location/Address of Work 2. Work Being Done For 3. Nature of Work: Road Cut (Complete Back of Form For Road Cut) (Please submit for review a copy of appropriate plans and proposed materials) 4. Working In/Near: Curb & Gutter Pathway/Sidewalk Street 5. Work to start on or after and shall be completed by 6. 7. Traffic Plan submitted and approved: City staff comment: APPLICANT INFORMATION (Please print): Name Phone E-mail Fax Address STREET CITY STATE ZIP CONTRACTOR OR PARTY PERFORMING WORK (Please print): License # Name Phone Foreman/Supervisor of Project Cell Phone E-mail Fax Address STREET CITY STATE ZIP Applicant Signature Date FOR ROAD CUT CONTINUE ON REVERSE SIDE FOR CITY USE ONLY AUTHORIZATION OF PERMIT FOR WORK WITHIN THE ROW/STREET OPENING Fee: $ Permit: ROW In consideration of agreement to comply in all respects with the regulations and codes of the City of Jerome covering such operations, and pursuant to authorization duly given by said City, permission is hereby granted for the ROW/Street work to be done as described in this application with said work to be done in accordance with special provisions as hereby stated: PUBLIC WORKS DEPARTMENT APPROVAL BY DATE ENGINEERING APPROVAL (If Required) BY DATE City of Jerome Permit to work within the Public Right-Of-Way (ROW) or Street Return to: City of Jerome, Public Works Department 152 East Avenue A Jerome, ID 83338 Phone: (208) 324-9669 Fax: (208) 324-6680 Yes No Not Required ---PAGE BREAK--- ROAD CUT INFORMATION Digline or One Call Registration Certificate Number Date and Time of Excavation Purpose of Excavation Method of Compaction Road Surface Restoration Required: Approved Plans Submitted: * Contractor is responsible for notification of Digline or One Call and private utility companies. * The Contractor shall have a certificate of insurance on file with the City of Jerome. * Excavations in the street must be restored the same day as opened unless specifically exempted by the City. Exemption Description Exemption Approved By * The bituminous surface must be restored per current edition of Idaho Standards for Public Works Construction (ISPWC). * The bituminous surface must be restored to finished grade the same day if no concrete work is necessary, or to bituminous base grade if concrete work is required. * When applicable, concrete work must be completed by the end of the next working day. Bituminous wearing surface must be restored to finished grade by the third working day. * Contractor is responsible for traffic control barricades and flashers). Traffic Control shall follow the most current version of the Manual for Uniform Traffic Control Devices (MUTCD) * Contractor must keep a minimum of one half of the street being excavated open to traffic or provide a temporary bypass road. Roadway and sidewalk surfaces must be kept in safe driving or walking condition at all times when open to the public. * Upon Completion of work, the site shall be restored to its original condition or better. * Prior to beginning work all necessary erosion control measures and traffic control shall be in place. * Contact the Engineering Division at (208) 324-9669 extension 220 prior to starting work and when work is completed. I have read the above information and understand City requirements to fulfill this permit agreement. Contractor Signature Date For City Use Only Completion Date Inspected By Original to Public Works Department Copy to Engineering Copy to Utilities if connecting to water, sanitary or storm Updated 02/17/2016 Yes No Yes No