Application And Permit
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1
2PERMIT NUMBER
APPLICATION AND PERMIT TO OCCUPY OR
PERFORM OPERATIONS UPON A STATE HIGHWAY
See Oregon Administrative Rule, Chapter 734, Division 55
CLASS :
KEY#
PURPOSE OF APPLICATION
GENERAL LOCATION
(TO CONSTRUCT/OPERATE/MAINTAIN)
HIGHWAY NAME AND ROUTE NUMBER
POLE
TYPE
MIN. VERT. CLEARANCE
LINE
HIGHWAY NUMBER
COUNTY
BURIED
TYPE
CABLE
BETWEEN OR NEAR LANDMARKS
PIPE
TYPE
LINE
HWY. REFERENCE MAP
DESIGNATED FREEWAY
IN U.S. FOREST
FEE AMOUNT
NON-COMMERCIAL
YES
NO
YES
NO
SIGN
APPLICANT NAME AND ADDRESS
MISCELLANEOUS OPERATIONS AND/OR FACILITIES AS
DESCRIBED BELOW
FOR ODOT USE ONLY
BOND REQUIRED
REFERENCE:
AMOUNT OF BOND
OAR 734-55
YES
NO
035(2)
INSURANCE REQUIRED
REFERENCE:
SPECIFIED COMP. DATE
OAR 734-55
YES
NO
035(1)
DETAIL LOCATION OF FACILITY(For more space attach additional sheets)
SIDE OF HWY OR
MILE
MILE
ENGINEERS
ENGINEERS
DISTANCE FROM
BURIED CABLE OR PIPE
SPAN
TO
TO
ANGLE OFCROSSING
POINT
POINT
STATION
STATION
LENGTH
CENTER OF PVMT
R/W LINE
DEPTH/VERT.
SIZE AND KIND
DESCRIPTION AND LOCATION OF NON-COMMERCIAL SIGNS OR MISCELLANEOUS OPERATIONS FACILITIES
SPECIAL PROVISIONS (FOR MORE SPACE ATTACH ADDITIONAL SHEETS)
TRAFFIC CONTROL REQUIRED
- OPEN CUTTING OF PAVED OR SURFACED AREAS ALLOWED?
YES [OAR 734-55-025(6)]
NO
YES [OAR 734-55-100(2]
NO (OAR 734-55-100(1)
AT LEAST 48 HOURS BEFORE BEGINNING WORK, THE APPLICANT OR HIS CONTRACTOR SHALL NOTIFY THE DISTRICT
REPRESENTATIVE AT TELEPHONE NUMBER:
OR FAX A COPY OF THIS PAGE TO THE DISTRICT OFFICE AT:
SPECIFY TIME AND DATE IN
THE SPACE BELOW.
A COPY OF THIS PERMIT AND ALL ATTACHMENTS SHALL BE AVAILABLE AT THE WORK AREA DURING CONSTRUCTION.
ATTENTION: Oregon Law requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-001-0010 through OAR 952-001-0090. You may obtain copies of the rules by calling the center at (503) 232-1987.
CALL BEFORE YOU DIG 1-800-332-2344
- ODOT USE ONLY
COMMENTS
IF THE PROPOSED APPLICATION WILL AFFECT THE LOCAL GOVERNMENT, THE APPLICANT SHALL ACQUIRE THE LOCAL GOVERNMENT
OFFICIAL'S SIGNATURE BEFORE ACQUIRING THE DISTRICT MANAGER'S SIGNATURE.
LOCAL GOVERNMENT OFFICIAL SIGNATURE
TITLE
DATE
X
APPLICANT SIGNATURE
APPLICATION DATE
TITLE
TELEPHONE NO.
X
When this application is approved by the Department, the applicant is subject to, accepts and
DISTRICT MANAGER OR REPRESENTATIVE
APPROVAL DATE
approves the terms and provisions contained and attached: and the terms of Oregon Administrative
Rules, Chapter 734, Division 55, which is by this reference made a part of this permit.
X
734-3457(2-06)
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