Franchise/License Rights-of-Way Diagnostic or Maintenance Notification Form

Roadways Requiring Construction and Restoration Permit

Maintenance or Diagnostic Work Within the Rights-of-Way for valid Franchise or ROW Licensees

Entities with a current, valid Franchise Agreement or Rights-of-Way (ROW) License with the City may perform diagnostic or maintenance functions to their facilities within the ROW, by acknowledging the following restrictions and providing notification, in advance of performing work within the ROW.

Work in County Rights-of-Way requires a County Permit

Work will take one day or less on the following date:
Work Performed Only 9am - 3pm *

Roads Requiring a Construction and Restoration Permit

Restricted Roads Requiring a Permit *
No signal shutdowns required *
Work does not impact others property *
No impacts shall be made to the structural integrity of roadways, sidewalks, existing landscaping or other property/infrastructure without a permit.
Work does not require confined space entry *
Confined space entry requires a permit.
Work is less than a $10,000 value *
If different from Franchisee/Licensee
Maintenance or Diagnostic and brief, general description.
Traffic Impacts
Traffic Plan

Utility agrees to implement the attached, temporary traffic control plan to mitigate impacts to motorized and non-motorized traffic, using the current version of MUTCD Section 6. 

Files must be less than 2 MB.
Allowed file types: jpg jpeg png html pdf.
SIGNATURE:

The undersigned affirms that he or she is an authorized representative of the applicant with authority to execute this work, and that all conditions and restrictions listed above have been met in compliance with the notification process for maintenance and diagnostic work without a Construction and Restoration permit.  

I hereby certify, on behalf of the applicant, that the information provided in this application is true and correct as of the date below and that the applicant agrees to abide by the obligations in TMC Chapter 3-6. 

Agreement Check *

Form last updated: July 2017

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