Permit Form

HAMILTON COUNTY PUBLIC WORKS
HIGHWAY DEPARTMENT
7625 STANDIFER GAP ROAD
CHATTANOOGA, TN 37421
PHONE: (423) 855-6100
FAX: (423) 855-6105
hamiltontn.gov/Department_Highway

R.O.W. & ROAD CUT PERMIT APPLICATION

AS A CONDITION OF THE ISSUANCE OF A PERMIT, APPLICANTS MUST PROVIDE PROOF OF LIABILITY INSURANCE WITH A MINIMUM POLICY IN THE AMOUNT OF ONE MILLION DOLLARS ($1,000,000.00).

Driveway Tile Information
ROW Restoration Work

ESTIMATED WORK TIMEFRAME

From Date:

To Date:

Plans are to be submitted

PROPERTY ADDRESS

Street Number:

Street Name:

City:

State:

ZIP:

OWNER DETAILS

First Name:

Last Name:

Phone Number:

Email Address:

Owner Address Same As Property Address

Street Number:

Street Name:

City:

State:

ZIP:

CONTRACTOR DETAILS

Company Name:

Subcontractor Name:

Contact Name:

Phone Number:

Email Address:

State License Number:

County License Number:

Plumbing License Number:

Remarks:

AFTER HOURS INQUIRIES

Name:

Phone Number:

Email Address:

TYPE OF WORK

Alteration
Repair/Replace

TYPE OF CUT

  Electrical
  Gas
  Sewer
  Telecommunications
  Water
  Other

DESCRIPTION - TOTAL LINEAR FOOTAGE

Boring perpendicular to center-line footage

Driveway or curb cut footage

Lateral Lane Cut footage

Linear Lane Cut footage

Right of way extending outside pavement footage

Boring in Right of Way footage

The contractor/utility shall keep a minimum of one (1) lane of traffic open at all times and work shall occur between 8:30am and 4:00pm, unless otherwise specified. The installation and maintenance of all traffic control devices shall conform to the guidelines for construction, maintenance, and utility work zone traffic control as outlined in the current edition of the Manual of Uniform Traffic Control Devices (MUTCD).

PLEASE CHECK WITH THE UTILITY COMPANIES AND 811 FOR LOCATION OF UNDERGROUND CABLES AND PIPES IN THIS VICINITY. YOU MUST CALL THE HIGHWAY DEPARTMENT TWENTY-FOUR (24) HOURS PRIOR TO BACK-FILLING.

NOTICE: This permit is granted upon condition that the work be done in accordance with the specifications adopted by the Hamilton County Highway Department, a copy of which may be had upon application to the Highway Department and must be kept on the premises and shown on demand.

Permittee must notify the Highway Department 24 hours prior to each of the following activities: excavation of trench; backfill of trench; and restoration of pavement.

Persons performing construction work under this permit must observe all Federal, State, and local laws and codes.

This permit becomes null and void if construction authorized is not commenced within 30 days, or if construction work is suspended or abandoned for a period of 30 days at any time after work is commenced.

I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any other state or local law regulating construction or the performance of construction.

By typing your name in the box below, you forgo a signature and authorize the submission of this document for review.