APPLICATION TO WORKALONG, ON AND ACROSS
XENIA TOWNSHIP ROADS WITHIN THE ROAD RIGHT OF WAY
(Authority: O.R.C. Section 5571.16)
Board of Trustees Xenia Township
8 Brush Row Road
Xenia, Ohio 45385
Phone: (937) 372-0859
Date:
Name of Applicant:
Address of Applicant:
Telephone Number:
The following is a complete description of the location, road and the type of work proposed to be completed by the applicant:
.
Work will commence on and will be completed on .
If Xenia Township will grant this permit I/we further agree to the following conditions:
1. That traffic shall be maintained at all times unless permission is granted by the Xenia Township Road Department to close the road;
2. That disturbance of road surface shoulders and ditches shall be kept to a minimum. Trenches shall be backfilled with clean 304 material and tamped in lifts of 12 inches so that settlement of the area does not take place. If settlement does occur, additional material of the same type shall be put into place and compacted;
3. That the road surface removed or damaged shall be replaced with 301 base asphalt plus 404 finish coat to a depth that was removed or a minimum of 2 ½” 301 plus 1 ½” 404, whichever is the greater, and the new surface shall be feathered onto and conform with the grade of the undisturbed surface and shall be repaired within four working days;
4. That lights, signs, barricades and, if necessary, flagmen and watchmen shall be placed on the job for the protection of traffic at all times, day and night, during the time this work is being done; and that instructions given by the Greene County Sheriff’s Department as to handling of traffic shall be fully complied with;
5. That I/we assume the responsibility for and shall save Xenia Township Trustees harmless from any and all claims for personal injuries and property damages, and shall defend any action that might be brought due to this work. To cover this responsibility, I/we have the following insurance which is now in force and shall remain in force during the prosecution of this work:
Amount For Policy Number Insurance Company
6. That the responsibility for work done under this permit shall remain in force and include the maintenance of the road for one {1) year after the surface has been replaced;
7. That all OSHA standards shall be followed to complete the work;
8. That a Performance Bond by a surety company licensed to do business In the State of Ohio, In favor of Xenia Township, be provided to Xenia Township. The amount of the Bond shall be $5,000.00 to cover the excavation and replacement of up to 650 square feet of pavement. If additional pavement is removed, additional Bond shall be provided at the rate of $8.00 per square foot. The cut in the pavement plus 6 feet In length shall be used in determining the square footage for figuring the amount of Bond rounded upward to the nearest $100.00. Bond for work in unpaved area of the road right of way shall be figured at the rate of $2.00 per square foot, culverts and bridges excluded. Copy of bond shall be filed with this application.
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BONDS SHALL REMAIN IN FORCE FOR ONE (1) YEAR FROM COMPLETION OF PROJECT OR UPON
RELEASE BY THE TRUSTEES.
Boring under the road must be a minimum of 30 inches deep within road right of way. (According to location)
I acknowledge the aforementioned conditions of this application.
(Signature of Applicant)
Reviewed by
(Road Superintendent) (Date)
***************************************************************
To be filled in by Xenia Township Trustees or Township Clerk
PERFORMANCE BOND:
(Amount)
DATE APPROVED:
FEES PAID: ($25.00)
Permission Is hereby granted to the aforementioned applicant to complete the work described In the application in accordance with the aforementioned conditions.
XENIA TOWNSHIP TRUSTEES
(Date)
The aforementioned work has Bond Expiration Date:
been completed, inspected and
approved by:
Bond Released by Trustees
Xenia Twp Road Superintendent
(Date)
Date:
Road Department Xenia Township Home Page
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