STREET CUT\MAIN TAPPING PERMIT TOWN OF PALMER LAKE OFFICE HOURS: 8:00 AM TO 4:30 PM 54 VALLEY CRESCENT MONDAY - FRIDAY P.O. BOX 208 PHONE: 719-481-2953 PALMER LAKE, CO 80133 FAX: 719-488-9305 THIS PERMIT IS REQUIRED FOR ANY EXCAVATION BEING PERFORMED ON THE RIGHT-OF-WAY WITHIN THE TOWN OF PALMER LAKE. THE RIGHT-OF-WAY CONSISTS OF ANY PROPERTY OWNED BY THE TOWN OF PALMER LAKE. PERMIT MUST BE REQUESTED 48 HOURS PRIOR TO THE PROJECT START AND MUST BE POSTED ON SITE. TOWN PERSONNEL MUST BE GIVEN 8 HOURS OF ACTUAL PROJECT START AND MUST BE PRESENT BEFORE ANY DIGGING IS STARTED. IN THE EVENT THE PROJECT CANNOT BE COMMENCED ON THE START DATE, NOTICE WILL BE GIVEN TO THE TOWN AT THE EARLIEST POSSIBLE TIME. RESCHEDULING MUST BE DONE WITHIN 30 DAYS OR THE PERMIT WILL BE CANCELLED AND THE APPLICANT WILL BE REQUIRED TO REAPPLY AND RESUBMIT THE NECESSARY FEES. FEE: $200* CHECK #: __________ DATE: _________ RECEIVED BY: ______________ * The Town reserves the right to waive or adjust any or all fees) This fee applies to the first twenty (20) feet of excavation. Additional footage will be charged at $10.00 per lineal foot. Contractor: ____________________________ Phone: ______________________________ Address: _______________________________ Cellular\Pager: _____________________ Has the Town been listed as an additional insured on the contractors liability insurance? Date & Time Cut\Tap is to be performed: _______________________________________ Location of Cut: ______________________________________________________________ Reason for Cut: Installation / Repair: WATER __ SEWER __ GAS __ ELECTRIC __ PHONE __ CABLE __ CULVERT __ OTHER __ Applicant is required to comply with all specifications adopted by the Town of Palmer Lake. Applicant assumes responsibility for replacement of asphalt on paved streets. All backfill will be compacted with Class 6 road base. The road surface will be returned to equal or better than original condition. All cuts must be inspected before and during backfill by a Town employee. Applicant is responsible for damage caused and will be charged time and materials for any repairs made by the Town of Palmer Lake. In the interest of public safety and the workers involved, applicant is required to comply with standards established in the manual of Uniform Traffic Control devices which performing any work on the streets of the Town of Palmer Lake. These standards will be implemented and supervised with the assistance of the Palmer Lake Marshals' Office. Circumstances may require a restricted "dig time" period due to the nature of the work involved, the particular street location and/or the needs of the driving public and will be decided on a case by case basis. Applicant will supply a rough drawing of the project area on (reverse side of permit). and maintain one (1) lane of traffic open at all times. Special Instructions on reverse side. Applicant will use an A.W.W.A. approved tapping machine. Service parts being installed must be of Town stock or equal quality. I have read and understand the above requirements: ____________________________ Applicant's Signature / Date Approved By: __________________________ Roadway Department __________________________ Water Department __________________________ Marshals' Office STREET CUT/MAIN TAPPING PERMIT TOWN OF PALMER LAKE OFFICE HOURS: 8:00 AM TO 4:30 PM 54 VALLEY CRESCENT MONDAY - FRIDAY P.O. BOX 208 PHONE: 719-481-2953 PALMER LAKE, CO 80133 FAX: 719-488-9305 Special Instructions: LEAVE ONE LANE OF TRAFFIC OPEN ________________________________ CONES OR BARRICADES REQUIRED ________________________________ FLAGMAN REQUIRED ________________________________ SCHOOL ROUTE WORK HOURS 9:30AM TO 2:00PM ________________________________ NOTIFY RESIDENCE ________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________