TOWN OF MENASHA Permit Fee $100.00

 

DITCH ENCLOSURE PERMIT Permit No. _____________________

Receipt No._____________________

 

TNBD Resolution No._____________

Date ___________________________

NAME_________________________________________________PHONE_________________________

ADDRESS_____________________________________________________________________________

______________________________________________________________________________________

LOCATION ____________________________________________________________________________

PERSON/CONTRACTOR PERFORMING INSTALLATION _____________________________________

______________________________________________________________________________________

Contact Person & Phone No. if different than above. _____________________________

______________________________________________________________________________________

The Applicant agrees to indemnify and hold harmless the Permitting Authority, its employees and its agents, from any cost claim, suit, liability and/or award which might come, be brought, or be assessed, because of the issuance or exercise of this permit, or because of any adverse effect upon any person or property which is attributed to the partially or entirely completed works of the Applicant. Accomplishment of the permitted work, or any part thereof, by or on behalf of the Applicant shall bind such Applicant to abide by this permit and all its conditions and provisions.

The permitted facilities shall, if necessary, be altered at the expense of the Applicant to permit alteration, improvement, or maintenance of the highway as may hereafter be ordered. The entire cost of constructing and maintaining the permitted facilities shall be the obligation of the Applicant unless a contract for such costs has been executed.

A copy of this approval, along with any plans and special provisions, shall be available on the job site.

Upon completion of the work, the Applicant shall notify the Town of Menasha Street Department at

920-720-7110 for final inspection.

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PERMIT APPROVAL BY PERMITTING AUTHORITY

The foregoing applications is hereby approved and permit issued by the Town of Menasha Board of Supervisors subject to full compliance by that the permitted work shall comply will all permit provisions and conditions listed on the reverse side hereof, special provisions as listed below or attached hereto, and any plans, details or notes attached hereto and make a part thereof. The applicant shall notify the Town of Menasha Street Superintendent 48 hours prior to the start of work. (920 720-7110)

BY _________________________________________ TITLE ____________________________________

(Signature of Authorized Representative)

 

DATE ____________________________________

PERMIT PROVISIONS AND CONDITIONS OF ISSUANCE

 

 

Pursuant to Wisconsin Statutes, this permit is granted to allow performance of the specific work described herein. The following standard provisions and any included special provisions shall govern:

 

(1) The Applicant agrees to indemnify and hold harmless the Permitting Authority, its employees and its agents, from any cost, claim, suit, liability and/or award which might come, be brought, or be assessed, because of the issuance or exercise of this permit, or because of any adverse effect upon any person or property which is attributed to the partially or entirely completed works of the Applicant. Accomplishment of the permitted work, or any part thereof, by or on behalf of the Applicant shall bind such Applicant to abide by this permit and all its conditions and provisions.

(2) The permitted facilities shall, if necessary, be altered at the expense of the Applicant to permit alteration, improvement, or maintenance of the highway as may hereafter be ordered. The entire cost of constructing and maintaining the permitted facilities shall be the obligation of the Applicant unless a contract for such costs has been executed.

(3) No open cutting for a crossing will be allowed where the pavement is too narrow to maintain one-way traffic at all times, unless the Permitting Authority has granted permission for a detour. Wherever the pavement is opened, the soil shall be hauled away and the trench shall be backfilled with sand or gravel and compacted in layers. The pavement removed for a road crossing shall be replaced as per the Permitting Authority specifications.

(4) When one-way traffic or a detour is used, the Applicant shall provide ALL NECESSARY SIGNS, FLAGMEN AND LIGHTS required according to the "Manual on Uniform Traffic Control Devices." When a detour is allowed, local newspapers may be notified by the Applicant in advance of the work being started, so deemed by the Street Superintendent.

(5) All disturbed areas shall be returned to their original condition or better, subject to the satisfaction of the Permitting Authority or its representative. Access to all private drives and public street intersections shall be maintained, and all disturbed areas completely restored.

(6) Any trenching, tunneling or excavating shall be performed in accordance with the requirements of OSHA and the Wisconsin Department of Industry, Labor and Human Relations, and any applicable local regulations.

(7) A copy of this approval, along with any plans and special provisions, shall be available on the job site.

(8) Upon completion of the work the Applicant shall file a written notice with the Permitting Authority.

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