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2. PERMITTEE INFORMATION
4. Applicant Name*
5. Company/Organization*
7. Contact Person*
8. Email Address*
10. Address
11. City
12. State
13. Zip Code
15. Phone Number*
17. FACILITY / PROPERTY OWNER INFORMATION
19. Business/Company Name*
20. Business/Company Phone Number*
21. Business/Company Email Address*
23. Mailing Address*
24. City*
25. State*
26. Zip Code*
28. CONTRACTOR INFORMATION
30. Company Contracted for Project*
31. Company Phone Number*
32. Company Email Address*
34. Project Supervisor Name*
35. 24-Hr Phone Number*
36. Supervior Email Address
38. Mailing Address
39. City
40. State
41. Zip Code
43. Does Contractor have a bond on file with the City?*

    1. Yes
    2. No
    3. Franchise Exception
44. If No, attached copy
48. RIGHT-OF-WAY INFORMATION

    If this is for the installation of new infrastructure, you must complete the R.O.W. Use Application

50. Select Relevant Field(s) for Work Scope*

    1. Storm Sewer
    2. Sump Pump
    3. Sanitary Sewer

    1. Water Service
    2. Street Repair
    3. Gas

    1. Telephone
    2. Electric
    3. Cable

    1. Small Wireless Cell
    2. Tree
    3. Other
52. If Other, Specify
54. PROJECT INFORMATION
56. Project Start Date*
    Project Start Date
57. Project Completion Date*
    Project Completion Date
59. Describe Project and Purpose*
61. Location of Right-of-Way Excavated*
63. Work will be done in*

    1. Street
    2. Alley
    3. ROW
    4. Easement
    5. Other
64. If Other, Specify
66. Total Number of Square Feet being Excavated for Project*
68. Describe the Material Installed in ROW*
70. Type of Excavation*

    1. Digging
    2. Trenching
    3. Boring
    4. Other
71. If Other, Specify
73. Surface Type Project Will Impact*

    1. Concrete
    2. Asphalt
    3. Sealcoat
    4. Gravel
    5. Grass
74. Party Responsible for ROW Restoration*

    1. Applicant
    2. Property Owner
    3. Subcontractor
76. COMPLIANCE AND SAFETY
78. Decribe Safety Measures*
80. Describe Traffic Control Plan (if applicable)
84. REQUIRED ATTACHMENTS
86. Engineering Site Plans: identifying current infrastructure, any manholes, sizes, types, and depth of any conduit or other enclosures*
88. Proof of General Liability Insurance: naming the city as an additional insured, not less than $1,000,000 with a maximum deductible of $5,000
90. COMPLIANCE ACKNOWLEDGEMENT
92.  *

    1. I certify that the information provided in this application, and in all supporting plans and documents, is true and accurate to the best of my knowledge and I acknowledge that I have a continuing obligation to inform the city if there is a change in the information contained in this application.
94.  *

    1. I acknowledge that the City of West Burlington shall be indemnified and held harmless for any damage arising from the project and shall defend the city in any related legal actions and cover any resulting judgments or decrees.
96.  *

    1. I certify that I have read and understand the requirements listed in Chapter 135 and Chapter 113 of the City of West Burlington, Iowa City Code.
98. Chapter 135
    Street Use and Maintenance
99. Chapter 113
    Use of Public Property and Rights-of-Way
101.  *

     1. I acknowledge compliance with all applicable state and federal laws, as well as city guidelines.
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103. Submit

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