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2. Permit No:__________________
   (Office Use only)
4. Town of Snowmass Village Right of Way Work Permit
   Public Works Road Division P.O. Box 5010, 3745 Owl Creek Road Snowmass Village, CO 81615 Phone: 970-923-5110 Fax: 970-923-3794
8. Instructions for Completion:

   This form is intended to be used as an electronic way to complete the information required for this permit only. Once the information has been entered into this form, additional documentation such as a diagram of work, will need to be submitted either by email or delivered to the Public Works office at 3745 Owl Creek Road. In addition to a diagram of work, a signed copy of this permit along with any fees (if applicable) may also be required once all information is submitted. Please follow up with the Public Works Department at 970-923-5110 after submittal of this form to ensure that application is complete. CALL BEFORE YOU DIG 1-800-922-1987. Right of way permits are valid for one (1) construction season, unless otherwise authorized by a Town of Snowmass representative.

10. Section I: GENERAL INFORMATION:
    (Allow 7 business days for permit approval)
12. Property Owner's Name*
13. Contractor*
15. Property Owner's Mailing Address*
16. Contractor's Mailing Address*
18. Owner's Phone No.*
19. Contractor's Phone No.*
21. Owner's Email Address*
22. Contractor's Email Address*
24. Town of Snowmass Contractor's License #*
25. Emergency Phone No.*
29. Section II: PROJECT INFORMATION:
31. Subdivision & Lot No.*
33. Work Location/Physical Address*

    Street address

35. Type of Work?*

    1. Trencher
    2. Boring
    3. Open Cut
36. New or Repair Work?*

    1. New
    2. Repair
38. Depth*

    If no road cut or trench within or alongside the public road is necessary, type "none"

39. Width*

    If no road cut or trench within or alongside the public road is necessary, type "none"

    
    

41. Purpose of Work?*

    1. Water
    2. Sewer
    3. Gas
    4. Electric
    5. Phone
    6. CATV
    7. Other
43. If you selected Other above, please describe*
45. Project Start Date*
46. Project End Date*
47. Length of Project*
49. SURFACE IMPROVEMENTS:
    Please provide the length x width in square feet for the appropriate improvement.
51. Asphalt Roadway*

    ____ Long x _____wide (SF)

    Type "0" if not applicable

52. Gravel Roadway*

    ____Long x ____wide (SF)

    Type "0" if not applicable

53. Concrete*

    ____Long x ______wide (SF)

    Type "0" if not applicable

54. Driveway*

    length of culvert

    Type "0" if not applicable

56. Documents Checklist:

    Traffic Control Plans, Landscaping Plans, Insurance Certificates, and Site Plans of work can be submitted separately to: sleeking@tosv.com, amartens@tosv.com, and jlouderback@tosv.com.

    
    

58. Traffic control plan*

    1. Yes
    2. No
59. Landscaping plan*

    1. Yes
    2. No
60. Insurance provided*

    1. Yes
    2. No
61. Diagram/Site Plan of Work*

    1. Yes
    2. No
63. Building Permit No.*

    Enter the TOSV Building Permit No. if a structure is involved. Type "none" if not applicable.

64. Engineer's Name*
66. Traffic Control Company*
67. Traffic Control Business Phone No.*
69. Traffic Control Supervisor*
70. Traffic Control Supervisor Phone No.*
72. Development Plan Approval Date*

    A development plan approval date will be required with a building permit. Type in "none" if not applicable.

74. Concrete or backfill and compaction methods for linear runs shall be tested by:
76. Engineer/Testing Company*
77. Engineer/Testing Company Phone No.*
78. Engineer/Testing Company Email*
80. Test results shall be emailed to the following Public Works staff emails within 24 hours after work is completed:

    Shaun LeeKing, Road Superintendent- Email: sleeking@tosv.com

    Anne Martens, Public Works Director- Email: amartens@tosv.com

    Julie Louderback, Public Works Admin. Asst.- Email: jlouderback@tosv.com

    
    

    
    

84. OFFICE USE ONLY:
86. Special Conditions Requirements:
    (Office Use Only. Permittee will be issued any special instructions below if necessary.)
94. Fee Structure
    (For office use only. Public Works to determine fees.)
96. Right of Way Permit Fee:
97. $300.00
99. Access Permit Fee:
100. $100.00
102. Obstruction Permit Fee:
103. $100.00
105. Total Permit Fee:
106. $_________________
107. Paid Check #:_____________
109. Right of Way Security Deposit: $2,000 minimum deposit for 2 years.
111. Right of Way Security Deposit for shallow utility cuts of 30" or less in depth: $20.00 per sq. ft. of asphalt cut equal or greater than $2,000.00 minimum.
113. Right of Way Security Deposit for deep utility cuts of 30" or more in depth: $30.00 per sq. ft. of asphalt cut equal or greater than $2,000.00 minimum.
115. Total Security Deposit: $______________
119. Section III: Contractor Acknowledgement
121. In accepting this permit the undersigned, representing the Permittee, verifies that they have read and understands all of the foregoing provisions; that they have authority to sign for and bind the Permittee; and by virtue of their signature the Permittee is bound by and agrees to comply with all Town ordinances, standards and specifications regulating construction.
123. Contractor Name*

     Type in name in place of signature

124. Date*
128. For office use only:
130. __________________________________________
     Permit Approval By
131. ___________
     Date
135. Inspected By:_____________________
     (For office use only)
136. Final Inspection By:_____________________
     (For office use only)
138. Security Deposit Released Date:___________
     (For office use only)
Leave This Blank:


140. 1. Receive an email copy of this form.
141. Email address

     This field is not part of the form submission.

142. Submit Submit and Print

* indicates a required field