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City of Puyallup I Engineering Services 333 S Meridian I Puyallup I WA 98371 Tel: (253) 841-5568 I Fax: (253) 840-6678 www.cityofpuyallup.org Rev: 09/12 CERTIFICATION: I certify that I have read this application and declare under penalty of perjury that the information contained herein is correct and complete. Signature of Applicant: Date City of Puyallup I Engineering Services RIGHT OF WAY PERMIT APPLICATION TRAFFIC CONTROL PLAN APPROVAL: (please attach proposed Plan if applicable) Date(s) of Traffic Control Plan is to be in effect: Time(s) of Traffic Control Plan is to be in effect: Approval contingency notes: PROJECT INFORMATION: Site Address: Parcel No: Zoning: Scope of Work: Provide a site plan showing location of proposed work APPLICANT Name: Address: City St Zip: Contact No: Email: City use only TCP APPROVED DATE: BY: WA STATE CONTRACTOR INFORMATION License No: Exp Date: City Business License No: Street Obstruction Bond: YES Current Insurance & CG2012: YES Named Authorized Company Employee: YES ---PAGE BREAK--- 2 of 2 CHECKLIST FOR RIGHT-OF-WAY PERMIT APPLICATION In order to review an application for a right-of-way permit, the City of Puyallup Engineering Services requires the following information: 1 completed Application Form – signed and dated. Site plan showing location of proposed work. Right-of-way plan review, permit and inspection fees: Right-of-way permit $80.00 Inspection $130.00 Traffic Control $90.00 THE FOLLOWING ARE THE REQUIREMENTS FOR OBTAINING A RIGHT-OF-WAY PERMIT: 1. City of Puyallup Business License Per PMC Chapter 5.04 2. $5,000.00 Street Obstruction Bond (on City of Puyallup form) and Power of Attorney attached. (Bond amount may vary depending on the size and scope of the project.) Per PMC Chapter 11.04.050 3. Certificate of Insurance evidencing Commercial General Liability Insurance with minimum limits of $1 million combined single limits per occurrence. The City of Puyallup shall be named as an additional insured under the applicants General Liability Insurance policy using ISO Additional Insured – State or Political Subdivisions – Permits CG 20 12 or a substitute endorsement providing equivalent coverage. Per PMC Chapter 11.04.050 4. Active Washington State Contractors License. Per Chapter 18.27 RCW 5. Authorization letter from the Company listing personnel authorized to obtain permits on their behalf. This letter is to be on Company letterhead and signed by the person signing the Street Obstruction Bond.