Application Form To Perform Subsurface Work In The Public Right-Of-Way
ADVERTISEMENT
1
2PERMIT # __________________
RIGHT - OF - WAY PERMIT
RECEIPT # __________________
(Subsurface)
DATE: _____________________
PUBLIC WORKS DEPARTMENT
FEE: _______________________
APPLICATION TO PERFORM
ENGINEERING DIVISION
414 E. 1
Street/P.O. Box 970
Expires: ________ Extended: _______
ST
SUBSURFACE WORK IN THE PUBLIC
Newberg, OR 97132
NW Natural PLAT # ________________
Tel: 503-537-1240
RIGHT - OF - WAY
NW Natural EJL # _________________
Fax: 503-537-1277
PGE WORK ORDER # ______________
INSTRUCTIONS:
Complete SECTION A – APPLICANT, and SECTION B – PROJECT INFORMATION. Incomplete applications may
delay processing of the permit. Please sign in Section E on the reverse side of this form where indicated.
This application shall not become an approved permit until signed by the applicant or an authorized agent
of the company, and authorized by a representative of the City of Newberg. If a certificate of insurance is
not on file with the City, it must be provided before a permit can be issued. Please provide three (3) sets of
construction plans and/or an area map for the proposed work with this completed permit application.
SECTION A – APPLICANT
Check one box below:
Specify name of company:
(if not utility company)
Portland General Electric
Contact Person:
Frontier
Email:
NW Natural
Mailing Address:
Comcast
Developer
Consultant
Business Tel:
24-hr Emergency Tel:
Fax:
Contractor
Institution
Public Agency
SECTION B – PROJECT INFORMATION
Project Location:
Nearest Cross Street or
Project Description:
______________________________
Landmark:
____________________________________
______________________________
______________________
JOB #:______________________________
Purpose of This Application:
____ Construct ____ Operate ____ Other
(check one)
(see misc. op. below)
Pole line:
Buried cable
(Type)
: (Type)
_____________________________
_____________________________
Pipe line:
Misc. Operations:
(Type)
(Maintenance, Repair, Etc. – Describe)
_____________________________
________________________________________________________
Plans Attached
Traffic Control Required
(check if yes)
(check if yes)
Bond Required
:
$ _____________________
(check if yes and indicate amount)
Estimated Dates:
Work To Be Performed By:
:
Utility Company
(check one)
Start Work _____________________
Sub-contractor: ____________________ Tel:
______________
Completion ___________________
Field Supervisor: __________ __ Cell Phone:
______________
Detail Location of the Facility:
(attach additional sheets if necessary)
Station To
Side of Street
Distance From
Buried Cable or Pipe
Pavement
Specify if Bore
Span
Station
or Angle of
Open Cut
or Other
Length
R/W
C/L
Depth
Size & Kind
Crossing
Method
Line
Yes
No
SECTION C – SPECIAL PROVISIONS
(this and next page – attach additional sheets if necessary)
0:\engineering\shared\templates\Developement Applications\Subsurface Utility ROW Permit_Application Form
Page 2
“Working Together For A Better Community – Serious About Service”
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business