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CITY OF JEROME PERMIT TO WORK WITHIN THE PUBLIC RIGHT-OF-WAY (ROW) or STREET Return To: City of Jerome, 152 E Avenue A, Jerome 1. Location/Address of Work 2. Nature of Work Street Cut: Full $1,200 Half $800 Alley Cut: Full $150 Half $150 (Complete back of form for street cut; submit a copy of plans and proposed materials for review) Curb Cut (contractor repairs) : $15 Install Curb & Gutter: Rolled Straight Back Driveway: Install Sewer Line $800 Install Water Line: (Cost depends on meter size) 3. Work to Start on or after and shall be completed by 4. Traffic plan submitted: Yes No N/A 5. Applicant agrees to have all utilities located prior to excavation: Initial Signature Date FOR STREET OPENING/CUT CONTINUE ON REVERSE SIDE For City Use Only Authorization of permit for work within the ROW/street or alley opening Fee: Permit: Road Cut Alley Cut Curb Cut 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. PW Dept/Engineering Approval BY Date Building Dept Approval Date HOMEOWNER INFORMATION (please print) Phone Email Address CONTRACTOR or PARTY PERFORMING WORK (please print) Name Office Phone Foreman of project Cell Phone Contractor registration number Email Fax Address SIGN ---PAGE BREAK--- Digline or One Call Registration Certificate Number Date & Time of Excavation Purpose of Excavation Method of Compaction Road Surface Restoration Required: Yes No ● Contractor is responsible for notification of Digline, One Call and private utility companies. ● 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 of 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 (e.g. 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 Dept at [PHONE REDACTED] Ext 222; Kelly Thomson [EMAIL REDACTED], prior to starting work and when work is completed. I have read the above information and understand the City of Jerome’s requirements to fulfill this permit agreement. Contractor Signature Date For city use only Inspected by Completion Date Original to Building; Copy to Engineering SIGN