Application for Permit to Work along or Across Miami Township Roads
225 Corry Street Permit
No:_____
Yellow Springs, Ohio
45387 Fee Paid:_______
Phone: 767-2460
P.O.
Address:___________________________________________________________
Make a complete statement of the type of work to be accomplished and
the exact location:________________________________________________________________________________________________________________________________________________________________________________________________________________
Road Name Start Date Number of days to
Completion
____________________ __________________ _____________________
____________________ __________________ _____________________
____________________ __________________ _____________________
____________________ __________________ _____________________
If this permit is granted, we I/we agree to the
following conditions:
1.
That traffic will be maintained at all times, unless
permission is granted by the Township Road Superintendent to close the road.
2.
That disturbances to road surfaces and shoulders will be
kept at a minimum and that trenches will be backfilled with gravel and tamped,
so that settlement of material will be minimized. If settlement does occur, an
additional suitable material will be put into place and compacted.
3.
That the road surfaces at the trench will be replaced with
material of the type that was removed and the new surfaces will conform to the
grade of the undisturbed surface.
4.
That lights, signs, barricades and, if necessary, flagmen
and watchman, will be placed on the job for the protection of traffic at all
times, day and night, during the time work is being done and that instructions,
given by the Township road Superintendent, as to handling of traffic will be
fully complied with.
5.
That I/we assume responsibility for protection of all
roadside utilities within the roadway and right-of –way and shall fully
compensate the affected utility for any damage or repair required as a result
of this work. Additionally, I/we shall contact OUPS at 1-800-362-2764 forty
eight (48) hours prior to starting work to ensure that all underground
utilities are marked, and shall fully compensate any affected utility for any
damage to their facilities.
6.
Concrete drive construction shall not extend beyond the
right-of-way or a minimum of five (5) feet from the edge of item 404 pavement.
7.
That responsibility under this permit will remain in force
until a release has been granted by Miami Township.
8.
That, I/we assume the responsibility for and will save the
Township harmless from any and all claims for personal injuries and property
damages, and shall defend any action that might be brought due to this work. To
cover this responsibility, I/we have the following insurance, $500,000.00,
which is now in force and will remain in force during the process of this work.
Insurance Company Name:____________________________
Policy Number:______________________________________
Liability Amount:____________________________________
Print Name:__________________________
Signature:_________________________
Address:________________________________________________________________
Phone Number:_______________________ Fax
Number:_______________________
To be Completed by the
Township Road Superintendent
Conduit Size Required:__________________
Type:______________________________
Adaquate sight distance: Yes ( ) No ( )
If no, see comments below.
Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________
Inspected by:___________________________ Date:____________________________
Permit to do this work under the conditions stated
in the above application is hereby granted subject to the applicant’s acquisition
of any and all other necessary authorizations including, but not limited to,
other necessary county agencies, townships, and other non township entities.
Such authorization must be obtained separate and apart from this application
_____________________________ _______________________
Miami
Township Zoning Inspector Date
A copy of this application is to be taken to the
Miami Township Road Department accompanied by a set of plans for the project,
if available
Please
contact the Miami Township Road Department at 937-767-7538 before starting the
project or if an emergency problem arises.