Street Opening / Right-of-way Excavation Permit Application

Applicant Information

Application Type (required)
Check All That Apply

Applicant Name (required)

Date (required)

Applicant Address (required)

Phone (required)

Fax # (required)

Email Address (required)

Person or Contractor Performing the Work
if Different than Applicant

Contact Name

Phone

Fax #

Email Address

Pavement Restoration Contractor
if Different than Applicant

Contact Name

Phone

Fax #

Email Address

Description of Work

Include specific details for the requested work including; dimensions, disturbed area, street map & nearest street address.

Emergency Work:  Yes No

Plans & Attachments:  Yes No

Location of Work
Check all that apply

Notes:
1. All work shall be in accordance with the Ordinance of the Municipality of Penn Hills as amended.
2. Final Inspection and acceptance of the work, including restoration, shall be at the discretion of the Municipality.

Composition of Surfaces in Excavation Areas
 Concrete Asphalt Brick Lawn Other

Start Date (required)

Completion Date (required)

PAOne Call Serial Number

Certificate of Insurance
Worker’s Compensation and Liability Coverage Required

Fee Calculation

Permit Application Fees

Base Application Fee
$

Supplemental Fee
Each Time Extension or Change request
$ x = $

Permit Inspection Fees

Surface Openings - Main Installation or Replacement
Minimum Fee for up to 100’ plus x amount per Linear Feet of Opening thereafter

Opening in Pavement or Shoulder
$250 for 1’ to 100’, $2.50 per foot over 100’
$ + = $

Opening Outside Pavement & Shoulder
$75 for 1’ to 100’, $0.75 per foot over 100’
$ + = $

 

Surface Openings - Service Connection or Spot Repair
Less than 36 square feet of opening, each opening

Opening in Pavement or Shoulder
No. of Openings x $ = $

Opening Outside Pavement & Shoulder
No. of Openings x $ = $

Note:
1. If an opening simultaneously occupies two or more highway areas, only the higher Fee will be
charged. Linear distances shall be measured to the nearest foot.

Additional Fees

If the Municipality anticipates that the cost of inspecting the permitted work will exceed the inspection fees above by a significant amount, additional Fees will be assessed. The Applicant will establish an Inspection Escrow Account with the Municipality via a Certified Check. All expenditures which exceed this amount will be paid by the Applicant. Any balance will be refunded to the Applicant.

Additional Inspection Fees
Amount determined by the Municipality in Escrow

TOTAL Application Fee

Issuance of Permit

Performance Security

No Permit shall be issued until the Applicant has furnished the Municipality with financial security for the proper restoration of the work. The security may be the form of a stated amount of not less than ($1,000) dollars or the Applicant may post, with the Municipality, a ($10,000) dollar security or larger if the Project is of unusual magnitude.

Performance Security furnished
 Yes No

Amount

or Franchise Agreement No.

Maintenance Security

Prior to Release of Performance Security by the Municipality, financial security in an amount equal to 50% of the Performance Security to guarantee the integrity of the restoration work for a period of (2) years after acknowledged completion of the work.

Certified Check Amount

Irrevocable Letter of Credit Amount

Escrow Account Amount

 

I, (Applicant/Authorized Representative) hereby agree to save the Borough, its Officers, Engineer, Police and Agents harmless from any & all costs, damages and liabilities which may accrue or be claimed to accrue by reason of such work performed under this Permit. The Applicant in accepting this Permit agrees to replace earth and pavement, in accordance with the Ordinance as amended, of the Municipality, within a reasonable time from the date of Permit, and place said (Street/Road) in the condition specified in said Ordinance. And the applicant also agrees to protect the opening by suitable barricade and light, in accordance with said ordinance, and to be liable for any damage of whatever kind that may be caused by reason of said opening, and also the whole expense of restoring, in accordance with the terms of said Ordinance, said (Street/Road) to as good condition as possible. The entire work shall be done in accordance with the Ordinances of the Municipality.

BY:

Name & Title (required)

Signature (required)