Form Mr 505 - Permits

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State of Ohio
1.
MR 505
Department of Transportation
App No __________
Office Use Only
Permit Application
County/
Jurisdiction________________
See Reverse side for additional requirements
Rte________ LogPt_________
AccCat_______
[1] This form must be completed by the property owner or agents working for a utility
company (if applicable). Application by contractor is unacceptable.
Name _______________________________________________________________
Address ________________________________________________City________________________________ State _______
Zip ________ Phone (
) _________________ Other (Fax, E-mail) _______________________________________
[2] Type of Permit requested: _____ Commercial (See other side) _____Residential ____Field ____Utility ____ Drainage
_____ Beautification (See other side) ____Spraying, trimming, tree removal _____ Other
[3] Briefly describe work to be performed. (Attach plans and see Instructions.)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Traffic Plan
_________________________________________________________________________________________
[4] Location where work is to be performed. Give sufficient detail to locate the site accurately, such as the distance in miles or
feet from a mile post or from some geographical feature such as an intersecting highway.
In ________________ County (along, across) State Route _________, _____miles or _____ feet
North __East__ West__South__ of_______________________________ on the North__East__West__South__side of the road.
Work to commence on ____________________ and will require __________ days to complete
[5] Does the property owner own or have any interests in any adjacent property?
____Yes _____No
If yes, please describe. _____________________________________________________________________________________
[6] Prior to any excavation in the highway right-of-way, the Ohio Utilities Protection Service (OUPS) must be contacted in
accordance with ORC Section 3781.25 to 3781.32. OUPS can be reached at 1-800-362-2764. A call must be made to OGPUPS at
1-800-925-0988.
[7] Open cutting of pavement shall not be permitted unless no reasonable alternate method is available. Written approval of the
Ohio Department of Transportation District Office must be obtained.
[8] All work requiring men or vehicles within ODOT right of way shall comply with all applicable requirements of the Ohio
Manual of Traffic Control Devices and Item 614 (Maintaining Traffic) of the Construction and Material Specifications, latest
editions. Failure to comply with these requirements will be cause for immediate revocation or suspension of the permit until the
proper traffic control devices have been provided.
[9] I have received a copy of the policies and regulations pertaining to the permit for which I have applied. If a permit is
subsequently issued to me by the Ohio Department of Transportation, I understand that the permit will state the terms and
conditions for its use, and I agree to comply with all conditions and regulations stipulated on or attached to the permit. I also
understand and agree that failure to comply fully with all conditions and regulations of the permit or any change in the use of the
permit inconsistent with its terms and conditions will be considered a violation and cause for suspension, revocation, or
annulment of the permit thereby rendering the permit illegal and subject to appropriate Department action, up to an including
removal of the installation at the permittee’s expense.
Office use only
________________________________________
SIGN and
_______________
Date Received
Signature of Property Owner or Agent for Owner
________________________
PRINT here
By
Date______________
_______________
Day time Phone __________________
Date Accepted
By ____________________________
Rev 7/8/05
(See Other Side)

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