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Home My WebLink AboutEXCAVATION PERMIT - 22-00501 - 26 E Main St - FIX A WATER LINE AND REPLACE PIPEe3'Dtp Excavation Permit Application IImo. : , f Y r PubUc works RF.XB I-.— 35NorthlsiCut( kai#xiOreabv8.or9 Mrahe: 208-M930N1aMM �xtxa¢O831x0 wwwsexbugorg _ face" 3.593022 APplicarsvcootractor: )D pltF N1ofK5 Mailing Address: J�V(A CLm2>1}C L.Qr'ie City: 2a% %ol a lQ _ swe: 10 tis B6+0 Primary Phone ([]Home -Work EACcio 2oY-'711e'_��'� Email: tCi.{�t-(') Excavation Address: 2(0 C. M!2tO S'keci- _DescnPtro°' FCS pt lYOYttix Y trip k)Y, YE(7Qif Location of Excavation: DSft=t D Alley KSidewalk D Undeveloped/Landscape Area �u1wZi Purpose of Excavation: V1k a w yklu- ((» t'Qt�IQU �s —Esc. Date:'/-� k (n - �.2 S'CO_ Refund Reci lent Name (if different from above): ACX N,ek<,1i phone #: - RefundRecipientAddreu: IlCln9 (',(0'rV%Q0Vl. lft_�a -City: anxh�State: In zip: .j3AAr0 CONDITIONS OF PERMIT: I.. No excavation within city right of way limits shall lake place prior to the issuance of an excavation permit 2. Property owners most be made aware of work happening adjacent to their parcels. An "Acceptance of Srutil" Repairs" form mrtst be signed by the property owners) prior to the excavation work being signed off by tho City. (Soo Attachment. A) 3. This permit expires 30 days after the issue date. Any work started and not completed witltia 30 days will be assessed a $100 weekly inspection fee until work finalized. 4. The connector is responsible for carrying a minimum of $500,000 genera, liability insurance coverage for possible damages during excavation. or other accidents. A certificate of liability is required and must be submitted via email at custamemen rc�-rexburg vrg. 5. The public right of way fee is 51,200 for my work that will disturb loss than 30 square yards of asphalt surthciag. A $200. porthmof this fee will be retained by the city for initial inspection costs. .6. Excavation work which disturbs more than 30 square yards of asphalt surfacing must be individually assessed by: the city for additional ties, 7. Ali utilities must be placed a wiwiwaur of 4 feet below the finished grade unless specfficallY authorized otherwise in writing. S. The contractor is responsible for contacting the city prior to placing bukfill materialand/or asphalt in city street locations. A city representative will then assess and, if acceptable, the excavation fee less inspection costs will be refunded within 30 calendar days of completion 9. if permit conditions are not met the city will hold fees for 1 year from final asphalt placement. If repairs are required, the contractor will be responsible for completing all repairs. if repairs are not made within 7 days, the city will complete repairs. The permit fee will be retained and any additional costa will be the responsibitity of the permit holder. 10. The contractor most notify Dig Line at I -SM -342.1585 at least two (2) business days in advance of the excavation date. i t. The contractor is responsible for furnishing and maintaining all barricades, signs, and flagmen as required by the Manual on Uniform Traffic Control Devices.(MUTCD). 12. Existing asphalt Pavement shall be saw cut prior to placement of asphalt to. provide a vertical surface. 13. Excavation and backfill work is to be completed in accordance with the requirements of Sections 300 and 800 of the Iddto Standatds.for Public Works Construction (1SPWC). (See Attachment B.) material, if acceptable bostockpiled or if not acceptable be immediately rcmovatdt�r+1. 4 fsxs+r+wt ,:s_ material needs to be kept a safe distance from trenches or traveled roadways 15. All strcetexcarations most be backfilled with 3 feet of flowable fill, 4 inches of/; inch crushed aggregate road base, and 2'h. inches minimum thickness of plant mix pavement surface or equal to the existing material thickness, whichever is greater. No exceptions unless pre -approved by city public works director. 16. Existing asphalt paverrtent shall be "racked" prior to new asphalt placement 17. Final repair of asphalt surfaces must be completed within 10 calendar days of the initial excavation. 18. No excavation permits will be approved firm November 10 - March 314 except in the case of an emergency which must be approved by the city public works director. Winter excavatio° requires a temporary cold mix paving to be placed and maintained by the contractor until the final paving is completed no later then May I'. in completing this application for an excavation permit, I hereby agree to all the above conditions as well as all applicable. City of Roxburg ordinances. S�ts12-1 Allpliciint Signal Date "Applicant will be mrtifred of permit application approval and request for a deposit to be submwedboweercavation can begin. (AtuchtkeatA)-•hs. -.. Sx:,.h- Acoepiaskt otSnrface Repoitat ati On this 2 day of'T 20121- ], the pastel owner c£tie papacy @.xakd at m Rcxbw& IdaL4 appove suslace repairs to my property omPbatc! by tie sxd COW& t. Hs",--a+'s`.::_t..- ��rs(s�* aitians. t;.�..a>.�S"^+L;.�..c •+f=.., `-.rv+.. ti..--.w..1.�+.''a.Y�-,«u�-;,`,....-.., `wwlF AcmptanceofSsrrfaeeRepairs � S1r tt4°y� Onthis _day of 20_I,the parcel ow= aftheprvo!hvk"edat . in pcjw&hwo6 Vpm yet repairs to my property completed by the noted cm mc.,:. ylN A*Ww-* PrmtedPropatyOwmaNamc SwLetntc Date _. Contact Number '� ,-P-►'a,xa �. .x = .,,�. �.uc �w_.�n:.;_ ,:�`r -� �, ,. �,.��:-err..:, aa:ssea;¢ - a�av�.✓v�v-..ml sir.. �l�v.�.��..6a..` r:lylib:ii �Yfu.::t'1�ucA f.4 ..i�.J'�..::�.. Y�:1_ .. u�_1IYaH� Acceptance ofSorface Rgmirs �133 On this-__davor 20_L .The tit tdowoerofthtwooatvtoestedat in Rexbw& Idaho, approve s4r au repa"trs to my prof camp:etM by the ttid xl crn:trr;te�. Printed Property Ovmer Name SiPatttre nye ContactNmnber ACORO® CERTIFICATE OF LIABILITY INSURANCE `---"� °ATE`"°"'°°"YyY' TYPEOFINSURANCE 1 05/24/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If S IS WANED, sobJect to the terms and_condlUons_of the pollcy, certain policies may require an endorsemer .�t%ement on , -''" '""-- "`� rt .not confer rights to the certificate holder in lieu of such endorsement(a . "' PRODUCER CONT KollerJ Jeppesen Western Community Insurance PROBE Eau. 20M24-3171 PAx , 208.624-3173 P.O. Box 4848 E-MAIL PP @idtbins.com MORES& kJl a seen Pocatello, ID 83205 INSURER(S) AFFORDING COVERAGE NM# INSURER A; Western Community Insurance Company 39519 ID INSURED INSURER B: JD Dirt Works LLC INSURER C: 1664 Clements Ln INSURER D: Rexburg, ID 83440 INSURER E: INSURER F: - - �- AUVeHgc;ra CERTIFICATE NUMBER: RFVIRInN NlnuRFR- ',G"v THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FORTHE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPEOFINSURANCE D OR POLICYNUMBER POUCYEXP MMND UMTTS A X COMMERCALGENERALUANLRY CLAIMS -MADE X OCCUR N N 8V471701 712/15/21 12115122 EACH OCCURRENCE $ 1;000,000 PREMISES noocummce - $ 100,000 MED EXP ore n $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENL AGGREGATE UMITAPPLIES PER: X POLICY ❑ jCRCT � LOC N OTHER GENERALAGGREGATE $ 2,000,000 PRODUCTS-COMP/OP AGG' $ 2,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS ONLY AUTOS D HIRED No WNED_._. AUTOS ONLY AUTOS ONLY - - �- - _ - COMBINED SINGLE LIMIT$ Ea wd enl BODILY INJURY (Per Damon), It BODILY INJURY(PorecdldeN)'. E PROPERTY DAMAGE M $ A UMBREUAUAB EXCESS LAB OCCUR CLAIMS.MADE EACHOCCURRENCE § AGGREGATE $ DED I I RETENTIONS $ A WORIERSCOMPENSAMONPER ANDEMPLOYERS'LIABILITY YIN ANYPROPRIETOWARTNERrFXECUTIVEACH OFFICCIUMEABEREXCUJDEDY ❑ (Mandabryln NFn IfyeIPTntler cess OeaN OF OPERATIONS below CE e, IO NIA 10 STATUTE I Er E.L. ENT AG $ E.1- DISEASE -EA EMPLOYEE It EL DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES (AOC)RD 101, Addltlonal Remarks Schedule, may be almched If mom specs Is required) City of Rexburg 35 North 1st East Rexburg, ID 83440 ACORD 25 (2016103) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The ACORD name and logo are registered marks of ACORD All rights reserved.