ROAD OPENING PERMIT |
CONEMAUGH TOWNSHIP, SOMERSET COUNTY |
Applicant Name: _________________________________________________________________ |
Applicant Address: _______________________________________________________________ |
Phone: ____________________________ Facsimile: ___________________________ |
Location of Work: |
Beginning Point: _________________________________________________________________ |
Ending Point: ___________________________________________________________________ |
Number of Openings: _____________________________________________________________ |
Combined length of cuts: __________________________________________________________ |
Description of Work: |
Describe project: ________________________________________________________________ |
List all materials to be installed (pipe, poles, valve boxes, etc.): ___________________________ |
_______________________________________________________________________________ |
Time Schedule for Work: |
Date of Start: ______________________ Completion Date: ____________________ |
The foregoing information is correct and complete to the best of my knowledge, information and belief, I understand that unsworn falsifications to public authorities constitutes a criminal act and is punished as a misdemeanor under the provisions of § 4108 of the Pennsylvania Crimes Code, being 18 Pa.C.S. § 4108. |
BY: _____________________________________________ (signature) |
type or print name here: _____________________________________ |
Title: ______________________ Firm: ____________________ |
Issuance Information (To be completed by Roadmaster) |
Permit Issued: _________________ Permit Expires: ________________ (4 months) |
Permit Fee: $ ____________ $20 plus $5 per each 100 ft., or part thereof over 50 ft. plus $25 for each open hole |
Inspection Fees: $______________ |
Total Fee: $___________________ |
Has Applicant submitted a Safety Plan? ____________________________________________ |
Approved on ___________________ by ______________________________________(signature) Conemaugh Township Roadmaster |
Conemaugh Township must be notified at least 24 hours in advance of beginning work and within 24 hours of completing work. Applicant must use PennDOT approved safety procedures for all work. Failure to comply shall be grounds for revocation of this permit. |
(Ord. 598, passed 5-10-1994; Ord. 619, passed 8-19-1998)