Internal-ROW-Permit-Application_HS28_FillablePage 1 of 3
Remit complete applications to: Direct Questions to: Development Services Right of Way Permitting Division
401 N. Elm St ROWpermitting@cityofdenton.com
Denton, TX 76201 940-349-7227
INTERNAL RIGHT OF WAY WORK APPLICATION FORM
I, (Print Name): _________________________ am with (Place of Business) _______________________, and
I am applying for a Right of Way (ROW) permit on behalf of (Department) ____________________ for the
purpose of performing planned work on (Department) _____________________ facilities within the public
ROW.
The work will take place at (Address/ Location of work) ________________________________________
And is planned to start on (date) _________________ and be completed by (date) ______________________
The type of work I will be performing is: (check one)
Planned Repair Planned Replacement Service Extension Service Removal Traffic Control Only Planned Replacement Forced Relocate
The scope and purpose of this work is (please describe)
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
The account number I will use to pay inspection fees is_________________________________________
My excavation plans are
No Excavation Directional Bore Trenching Hand Digging Excavating paving
Other (explain) __________________________________________________________________
__________________________________________________________________________________
The excavation details are:
LOCATION
(IN STREET, ALLEY, BEHIND
CURB, ETC.)
DIMENSIONS
(LENGTH X WIDTH)
MATERIAL
(ASPHALT, CONCRETE, GRAVEL; OR
SPECIFY IF OTHER TYPE)
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Below is my contact information:
Contact Name:______________________________Company Name:____________________________
Address:___________________________________City:__________________State:______Zip:________
Phone:______________________Cell Number:__________________________
Fax:________________________ Email Address:_____________________________________________
Below is the project manager’s contact information:
Check if same as above (ROW user will be performing work).
Contact Name:______________________________Company Name:____________________________
Address:___________________________________City:__________________State:______Zip:________
Phone:______________________Cell Number:__________________________
Fax:________________________ Email Address:_____________________________________________
Below is the electrical sub contractor’s contact information:
N/A Check if same as above (ROW user will be performing work).
Contact Name:______________________________Company Name:____________________________
Address:___________________________________City:__________________State:______Zip:________
Phone:______________________Cell Number:__________________________
Fax:________________________ Email Address:_____________________________________________
Below is the sub contractor’s contact information:
N/A Check if same as above (ROW user will be performing work).
Contact Name:______________________________Company Name:____________________________
Address:___________________________________City:__________________State:______Zip:________
Phone:______________________Cell Number:__________________________
Fax:________________________ Email Address:_____________________________________________
*Attach a separate sheet if additional space is required*
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I understand that documentation required with an application form may include, but is not limited to: A Construction Plan, illustrating the geographical location and extent of the work zone; placement of the applicants existing and proposed facilities; areas which will be excavated; and the staging area for equipment
and vehicles. If work is aerial, the pole number and ownership for each pole must be labelled. A Traffic Control Plan (TCP), in compliance with the Texas Manual of Uniform Traffic Control Devices. A TCP is required for all non-residential street applications. Utility Details showing the profile or cross section of bores; demonstrating a minimum separation of 24
inches from the nearest edge of a city facility; and minimum depth below top of curb, or lowest grade if no curb, of 36 inches.
Restoration Plan, if a total area greater than 50 cubic feet will be disturbed; illustrating all areas to be excavated and materials which will be used for repair.
Erosion Control Plan, if excavation will disturb a total area greater than one acre. City Standard Details; for repair of paving excavations. Letter of Authorization from a third party or property owner indicating acceptance of activities associated with the proposed scope of work on another’s property, such as TxDOT, DME, or UPRR. Public Notice, flyer, door hanger, or other informational material to be distributed by the applicant to property
owners adjacent to the work zone to notify them of work to take place, at least three business days in advance.
Certificate of Insurance, providing proof of minimum public insurance coverages established by city ordinance.
Before and after images of any above ground installation (pole, sign, marker, pedestal, meter, hand hole, etc.), at street view.
Surety Bond, with minimum coverage established by city ordinance.
Inspection Fees, established by city ordinance and/or the terms of a valid municipal agreement.
By initialing, I confirm that the statements below are correct:
_____ I confirm that I have current, proper authorization and certification to work within city ROW
_____ I confirm that I am the ROW user (not a sub-contractor)
_____ I understand that incomplete applications will not be considered
_____ I understand filling out this application does not guarantee the permit will be issued
_____ I have read and understand the required attachments listing, and have provided all applicable attachments
Print Name_______________________ Date________________
Signature__________________________