APPENDIX A: FORMS AND PERMITS

TOWN OF SALEM

APPLICATION FOR ROAD CONSTRUCTION PERMIT

I hereby apply for a permit to construct a road, drainage or make other improvements in accordance with the design and construction specifications of the Town of Salem, Connecticut

LOCATION: ________________________________________________________________________

OWNER: ________________________________      PHONE: _____________________________

ADDRESS: ______________________________      EMAIL: ______________________________

DEVELOPER: ___________________________      PHONE: ______________________________

ADDRESS: ______________________________      EMAIL: ______________________________

GENERAL CONTRACTOR: _______________      PHONE: ______________________________

ADDRESS: ______________________________      EMAIL: _______________________________

NAME OF SURETY COMPANY: ________________________________________________________

AMOUNT OF SURETY BOND: ________________________________________________________

APPROXIMATE TIME REQUIRED TO COMPLETE WORK: _______________________________

DESIRED STARTING DATE: ___________________________________________________________

ISSUE PERMIT TO: _________________________________________________________________

ADDRESS: _______________________________      PHONE: _______________________________

                           EMAIL: _______________________________

Submit two (2) copies of street rights-of-way and any easements for drainage:

MAP TITLE: ______________________________________________________________

ENGINEER: ______________________________________________________________

Before this permit is issued, I agree to furnish the required bonds and any required inspection fees, as outlined in the DESIGN AND CONSTRUCTION STANDARDS of the Town of Salem.

An application fee of $100 is submitted herewith.

__________________________________

Applicant

Town of Salem

APPLICATION FOR EXCAVATION PERMIT
OF AN EXISTING TOWN ROAD

Application is hereby made for a permit to excavate at:

____________________________________________            __________________________

Street address                              Assessor Lot #

For the purpose of ____________________________________________________________________

PROPERTY OWNER: _________________________________________________________________

ADDRESS: _______________________________      PHONE/EMAIL: ______________________

PERMIT VALID FROM _______________________________   TO __________________________

Excavation plans shall be submitted with this application or a sketch of the excavation shall be shown on the back of this application.

SPECIAL CONDITIONS:

Any excavation remaining open overnight shall be properly fenced and lighted. ______________

    ______________________________________________________________

    ______________________________________________________________

Site inspected and approved for excavation: _______________________________      _____________

                                 Public Works Director            Date

Under the Code of Ordinances for the Town of Salem, a current certificate of insurance and a surety bond shall be on file in the Public Works Department or First Selectman’s office before this Excavation Permit can be issued.

The undersigned hereby agrees that if approval is granted to excavate as requested in this application, that the Town of Salem will be held harmless and free from any liability for damages caused by reason of such excavation, and further, that if at any time within one (1) year from the date of this application’s approval the excavation has not been properly filled and the street restored to as good a condition as it was before excavation, the Town of Salem may repair same and charge the expense to the undersigned.

NO EXCAVATION SHALL TAKE PLACE IN REGARDS TO THIS APPLICATION UNTIL THREE (3) DAYS AFTER THE DATE OF APPROVAL.

Application Date: _____________________      Applicant’s Signature: _______________________

Company Name: _____________________      Phone/Email: _____________________________

Address: ___________________________________________________________________________

FINAL INSPECTION: _____________________________________   DATE: _______________

            Public Works Director/First Selectman

(Ord. passed 1-11-1984)