PERMIT NUMBER:
DATE PERMIT ISSUED:
VILLAGE OF APPLE CREEK
ROAD OPENING (WORK and/or EXCAVATION WITHIN VILLAGE RIGHT-OF-WAY)
PERMIT AND PERMIT APPLICATION
Date:
APPLICANT AND LOCATION INFORMATION:
* Applicant Name: Phone #:
* Mailing Address:
* Work to be performed by (circle one) APPLICANT CONTRACTOR
If work to be completed by Contractor, submit contractor information:
* Name of Contractor:
* Address of Contractor:
City/State Zip Code:
* Phone # of Contractor:
* To work within the Village right-of-way at the following location:
* The work is necessary for the following reason(s):
* Anticipated start date of work:
* Anticipated completion date of work:
EXCAVATION INFORMATION (If work described above involves excavation, complete this section. If work does not involve excavation, skip this section):
* Estimated Dimensions of Excavation (length, width and depth):
* Excavation to be within (circle all that apply):
Asphalt Pavement Concrete Pavement Brick Pavement
Grassed Tree Lawn Area Concrete Sidewalk Other
APPLICANT RESPONSIBILITY
If this permit is granted, I/we agree to comply with all the conditions, restrictions and regulations of the Village of Apple Creek. I/we also agree to notify the Village a minimum of twenty-four (24) hours in advance of any work. I/we also understand that it is solely my/our responsibility to notify the Ohio Utilities Protection Service (OUPS) a minimum of forty-eight (48) hours in advance of any excavation.
If this permit is granted, I/we agree and acknowledge hat it is solely my/our responsibility to return the affected area to its original condition as soon as reasonably possible. I/we also understand that the Village of Apple Creek may require the issuance of a surety bond, deposit, or other financial guarantee to cover the cost of any restoration work. A written summary of this requirement will be attached to the permit.
I/we also agree that while excavating within the Village right-of-way, I/we will utilize signs, lights, barricades, flagmen and/or watchmen as necessary to ensure the safety of both the construction workers and the traveling public. All said safety devices shall be in compliance with the Ohio Manual of Uniform Traffic Control Devices for Streets and Highways.
I/we understand that this work is being completed within the Village right-of-way. As such, I understand that the Village maintains the right to remove, alter, or otherwise disturb this area for any reason.
Applicant Signature
Applicant name (please print)
Status of Permit:
Approved (approval date: )
Rejected (rejection date: )
Reason for Rejection:
Mayor’s signature:
(Ord. 2018-17, passed 12-3-2018)