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HomeMy WebLinkAboutIowa Department of Transportation-10/17/20160), IOWA OOT Form 810028 (01-14) APPLICATION TO PERFORM WORK WITHIN STATE HIGHWAY RIGHT-OF-WAY FOR DEPARTMENT USE ONLY Permit Number Highway Number (SEE ATTACHED LISTING) County Black Hawk DOT Project Number N/A Expiration/Completion Date 04/15/17 APPLICANT (INDIVIDUAL OR COMPANY) (ASSISTANCE FROM DEPARTMENT AVAILABLE UPON REQUEST) First Name Tony Middle D Last Name French Phone Number 319-610-1171 Ext. Company Name Five Star Snow Trails, Inc Phone Number 319-610-1171 Ext. Street Address 2202 Minnetonka Drive City/Town Cedar Falls State IA ZIP Code 50613 WORK TO BE ACCOMPLISHED Approval is hereby requested to enter within the state right-of-way and to complete the proposed work as detailed on the attachments and further described as follows: Snowmobile Trail and Trail Crossing Locations as indicated on the attached listing. Trail is located partially within the city limits of Dunkerton and Waterloo. All crossings shall go into effect after all signs along the highway have been installed by IDOT forces. All signs placed on the ROW by the applicant shall be removed by the applicant. and shall be located as shown on the detailed plan attached hereto. (See current Iowa Department of Transportation Utility Accommodation Policy for submittal of detailed plan requirements.) WORK SITE LOCATION The proposed work as described above is located in Section , Twp. (SEE ATTACHED LISTING) Range (SEE ATTACHED LISTING) on Highway No. generally located (miles) (direction) from (city, county line, or other land line). Work proposed is more specifically located as being from (Milepost#) and (Highway Station) to (Milepost #) and (Highway Station) on the side of highway. Applicant Signature and Agreement The undersigned have read the stipulations of this permit agreement as stated as well as attachments which may be included and by signing this application agree to abide by all stipulations and to complete the work as proposed in compliance with the stipulations and attachments within one year from the date Department approval is received for said request. Failure on the part of the applicant to abide by the stipulations or to construct the work desired as stipulated and within the time frame stated shall render this agreement and request null and void. The undersigned also agrees to save harmless the State of Iowa and the Iowa Department of Transportation from any damage or losses that may be sustained by any person or persons on account of the conditions and requirements of this agreement. Applicant Name (First, M.l., Last - Print or Type) Applic Signature (Hand (ten) Date Tony D. French `do -2, €:5, e c CITY ACTION (IF PROPOSED WORK 1S WITHIN AN IiORPORATED CITY, CITY ACTION IS REQUIRED) "The undersigned city joins in the grants embodied in the above permit executed by the Iowa Department of Transportation on condition that all of the covenants and undertakings therein running to the Iowa Department of Transportation shall inure to the benefit of the undersigned city and recommends action on said permit application as noted below by the delegated city official". El Recommend Approval ❑ Do Not Recommend Approval El None Required Handwritten Signature Title Date Type or Print Name (Sh;h ATTACHED CITY ACTION SHEETS) Authorized Official for the City of (SEE ATTACHED CITY ACTION SHEETS) FEDERAL HIGHWAY ADMINISTRATION ACTION (DEPARTMENT REPRESENTATIVE WILL REVIEW THE REQUEST AND OBTAIN FHWA ACTION, WHEN NECESSARY) ill Recommend Approval 0 Do Not Recommend Approval j None Required Authorized FHWA Representative Signature Date (DOT Final Action and Agreements on next page) Page 1 of 2 DEPARTMENT OF TRANSPORTATION FINAL ACTION Application Approved ❑ Application Denied Permit Number: Authorized Highway District Representative Daryl Erickson, EOT Signature Date Notice of intention to commence activities on the highway rights-of-way shall be submitted by the applicant a minimum of 48 hours prior to actually commencing the activities as herein granted by this approved application. Notice is to be given to the following Iowa Department of Transportation representative: Local DOT Contact Person (Type or Print Name) Barry Thede Waterloo Area Supervisor Phone Number 319-233-3055 Street Address 1875 West Ridgeway Avenue City/Town Waterloo State IA ZIP Code 50704 AGREEMENTS The applicant agrees that if granted a permit to do said work the following stipulations shall govem. 1. The applicant shall carry on the construction, repair, and maintenance with serious regard to the safety of the traveling public and adjacent property owners and shall save the State and the Iowa Department of Transportation harmless of any damage or losses that may be sustained by the traveling public on account of such construction, repair, or maintenance operations. 2. The applicant shall indemnify and save harmless the State of Iowa, its agencies, and employees, from any and ail causes or actions, suits at law or in equity, for losses, damages, claims, or demands, and from any and all liability and expense of whatsoever nature, arising out of or in connection with the applicant's use or occupancy of the public highway. 3. The applicant shall hold the State and the Iowa Department of Transportation harmless of any damage that may result to said highway because of the construction or maintenance of the facility, and shall reimburse the State or the Iowa Department of Transportation for any expenditures that the State of Iowa or the Iowa Department of Transportation may have to make on said highway rights-of-way on account of said applicant's construction or maintenance activity or lack thereof. 4. Traffic protection shall be in accordance with Part VI of the current Manual on Uniform Traffic Control Devices for Streets and Highways. The applicant shall be responsible for correctly using signs as needed while work is in progress. Flagging operations are the responsibility of the applicant. 5. Before beginning any work within the highway rights-of-way, it is the responsibility of the applicant to contact utility companies whose installations may be affected or encountered. Contact should be made at 1-800-292-8989, a minimum of 48 hours in advance of starting construction. If the work requested in this application should cause a need to relocate or modify an existing utility, any cost associated shall be as negotiated between the applicant and the utility owner. 6. A copy of the approved application shall be available on the job site at all times for examination by Department of Transportation officials. 7. The applicant shall seed and mulch all disturbed areas within the highway right-of-way and shall be responsible for the vegetative cover until it becomes well established. Any surfaced areas such as driveways or shoulders and sodded waterways and plantings which are disturbed shall be restored to their original condition. 8. If the proposed work results in a pool of water on the applicant's property, this pool of water will be exclusively owned, controlled, and maintained by the applicant. That part of the modification located on highway right-of-way will be maintained by the Iowa Department of Transportation for road purposes only. 9. The applicant shall maintain any drainage structure built within the right-of-way that is built for the benefit of the applicant and not necessary for highway use. 10. This permit is subject to any laws now in effect as well as any new laws which may be hereafter enacted and all applicable rules and regulations of local, state, and federal agencies. 11. This permit is subject to all the rules and regulations of the Iowa Department of Transportation, and to revocation by the Iowa Department of Transportation at any time and at no cost to the Department, when in the judgment of the Department it is necessary in the improvement or maintenance of the highway or for other reasonable cause. 12. The applicant agrees to give the Iowa Department of Transportation 48 hours notice of intention to start construction or perform maintenance on the highway right-of-way. Any modification to the proposed work shall be approved by the Department prior to making the change. 13. Unless specifically noted in item #15, all work performed within the right-of-way shall be restricted to a time frame of 30 minutes after sunrise to 30 minutes before sunset. 14. After November 24, 2008, all personnel in the highway right-of-way shall wear ANSI 107 Class 2 apparel at all times when exposed to traffic or construction equipment. 15. All proposed work covered by this permit shall be at the applicant's expense. The applicant shall reimburse the lowa Department of Transportation for any materials removed from the highway right-of-way described as follows: 16: The following special requirements -shalt apply -to this permit PLEASE NOTE: The sponsor agrees to hold harmless the State of Iowa and the Iowa Department of Transportation and to indemnity them from any claim, demand or action by or on behalf of any person or entity arising out of or in connection with anything having to do with the snowmobile route, including, but not limited to, its establishment, construction, use, maintenance, signing, configuration or existence. Disclosure Statement: The information fumished on this form will be used by the Department of Transportation to determine approval or denial of the application. Failure to provide all information will result in denial of the application. Information fumished is public information and copies may be provided to the public upon request. Page 2 of 2 CITY ACTION (IF PROPOSED WORK IS WITHIN AN INCORPORATED CITY, CITY ACTION IS REQUIRED) "The undersigned city joins in the grants embodied in the above permit executed by the Iowa Department of Transportation on condition that all of the covenants and undertakings therein running to the Iowa Department of Transportation shall inure to the benefit of the undersigned city and recommends action on said permit application as noted below by the delegated city official". Recommend Approval 0 Do Not Recommend Approval 0 None Required Handwritten Signature c.) -L-1.1/1/ t Title 34:1r— Date 1®l i i /1 L Type or Print Name Authorized Official for the City of WATERLOO 3A TO: CITY CLERK In re-evaluating the process that we have been following for many years, we have come to the conclusion that it is possible to substantially reduce the amount of paper copies we have been generating. Starting with this APPLICATION TO PERFORM WORK WITHIN STATE HIGHWAY RIGHT-OF-WAY, we are requesting that you retain all of the documents included with this package except the single sheet that is signed by your City Official. It is suggested that you make a copy of the signed sheet to keep with the package and mail the original back to us in the postage applied envelope. This package of material becomes your temporary file copy, pending approval by the IDOT. When we have received the signed copy from the IDOT with the permit number, a final copy of the IDOT form 810028 will be sent to replace the copy you received with this package. Last evening, we completed our processing of the application and ready to deliver today. This morning we received a copy of the 2016 insurance certificate from the insurance agency. Do to this, we have made pen changes to the letter of instructions. We hope that this is not too confusing, but in the end it will "save the trees" by reducing the number of paper copies produced. Thank you. COMPLETE THE SIMILAR SECTION SHOWN ON PAGE 1 OF THE APPLICATION October 4, 2016 City of Waterloo Attn: City Clerk 715 Mulberry Street Waterloo, IA 50703 FIVE STAR SNOW TRAILS ASSOCIATION, INC. 2202 Minnetonka Drive, Cedar Falls, IA, 50613-1522 Ph: 319-266-2929(H) • 319-610-1171(C) ♦ Email: frenchtd1(d vahoo.com Enclosed for your consideration is the Application to the Iowa Department of Transportation (IDOT) for renewal of the permit to establish and sign a snowmobile trail within the right-of-way of State highways. A portion of that trail resides within the City limits of Waterloo. The IDOT requires that each affected City approve the application before being processed by the Department. individual representing Waterloo Page 3A of the application has a block for the signature of the responsible PLEASE USE THIS PAGE FOR THE CITY SIGNATURE. 00 NOT Permits are issued for one season only and must be renewed each year. This application is the same as the one which was approved last year for the City of Waterloo. Items 1, 2 on page 4 and item #17 on page 5 are the only items that currently affect Waterloo. ". If you have any questions concerning the application and related paperwork, you may contact me at: 319-610- 1171(Cell) or e-mail to: frenchtdl@Yahoo.com I would appreciate it very much if City action could be taken at the October Council meeting, if Council action is required. It is imperative that we get the application in the hands of the IDOT as soon as possible, so as to beat the freezing temperatures and first snowfall with installation of the signs along the trail. Please return the signed copy to me in the enclosed, "postage applied" envelope as soon as possible after action has been taken by City Officials. Thank you for your assistance with this matter. Sincerely, 70/44, 7frepte4 Tony D French Five Star Snow Trails Assoc., Inc. Administrative Advisor IOWA DEPARTMENT OF TRANSPORTATION Application to perform work within State Highway Right -of -Way FIVE STAR SNOW TRAILS ASSOCIATION Snowmobile Trail and Crossing Locations -Black Hawk County 1. Crossing of US 218 in Waterloo at Marigold Dr, milepost 176.84. 2. Marked, "ungroomed" trail along east ditch of US 218 from Marigold Dr in Waterloo, milepost 176.84, to bridge at the north Washburn city limits. 3. Install a temporary bridge in the east ditch of US 218 over the small creek at the north Washburn city limits. (NO SIGNING REQUIRED ON ROADWAY) 4. This item was completely removed and the number retained to avoid renumbering balance of items. 5. Marked, "groomed" trail along east ditch only, of US 218 from the convenience store at 7112 LaPorte Road in Washburn to East Schrock Road, southeast of Washburn. 6. Crossing of US 218 at East Schrock Road, milepost 173.74. 7. Marked, "groomed" trail along both ditches of US 218 from East Schrock Road, milepost 173.74 to LaPorte City north city limits. 8. This item was completely removed and the number retained to avoid renumbering balance of items. 9. This item was completely removed and the number retained to avoid renumbering balance of items. 10. This item was completely removed and the number retained to avoid renumbering balance of items. 11. Crossing US 218 at West Gresham Road north of Cedar Falls. Stop signs will be placed along the trail on both sides of the highway requiring snowmobiles to stop prior to crossing the first two lanes and also in the median to require snowmobiles to stop before crossing the next two lanes. 12. This item was completely removed and the number retained to avoid renumbering balance of items. 4 Black Hawk County-2016.docx IOWA DEPARTMENT OF TRANSPORTATION Application to perform work within State Highway Right -of -Way FIVE STAR SNOW TRAILS ASSOCIATION (Cont'd) Snowmobile Trail and Crossing Locations -Black Hawk County (Cont'd) 13. Crossing of I-380/US 20 at intersection with County V49. Club will install signs to direct Groomer and snowmobiles to cross over I-380/US 20 on the overpass bridge and not cross at grade. "No Snowmobiling" signs will be placed along the "on" and "off' ramps on both sides of the freeway. Trail marker signs will be installed along the bridge deck, milepost 66.52. 13A. Along IA 281, trail exits private property via farm field driveway approx 150 ft west of bridge over creek. Milepost 21.61 13B. The trail then proceeds east along shoulder to cross bridge, then along shoulder approx 150 ft east of bridge to farm field driveway where it enters private property again. This location is approx halfway between Goeller Road & Black Hawk Buchanan Road (County V62). Milepost 21.72 14. Crossing of IA 281 at the alley between Main St and the bridge over the creek in Dunkerton. 15. This item was completely removed and the number retained to avoid renumbering balance of items. 15A. Crossing IA 281 (Independence Ave) east of Waterloo, approximately .90 mile east of intersection with County V43 (Elk Run Road) & approximately .10 mile east of property address 4914, immediately east of the blue "Litter Removal" sign, where trail uses field driveways on either side of the highway. Milepost 4.63. 16. Crossing of IA 281 at County C57, milepost 16.64 17. Crossing of US 63 at Airline Highway in Waterloo. Milepost 166.71. 18. Crossing of US 63 approx .25 of a mile north of West Bennington Rd and approx 170 feet north of the small green highway milemarker 171. This location is a highway "turn -around" with farm field driveways coming directly from both the east and west farm fields, milepost 171.03. 5 Black Hawk County-2016.docx IOWA DEPARTMENT OF TRANSPORTATION Application to perform work within State Highway Right -of -Way FIVE STAR SNOW TRAILS ASSOCIATION (Cont'd) Snowmobile Trail and Crossing Locations -Black Hawk County (Cont'd) Note: Marked, "groomed" trail indicates that a track driven motorized trail grooming tractor pulling a snow drag will be operating to prepare the trail for snowmobile use and special signs applicable to snowmobile trails will be installed. Note: Liability insurance for the Five Star Snow Trails Association is covered on the "Land Owners as Additional Insureds" page on the enclosed Certificate of Insurance for the Sno Hawks Snowmobile Club. All towns involved and the Iowa Department of Transportation are covered by the additional insured that is listed as "THE STATE OF IOWA AND ALL OF ITS POLITICAL SUBDIVISIONS". 6 Black Hawk County-2016.docx ACcRtf CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/TYYY) 10/03/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, BELOW. 1415 CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the If SUBROGATION IS WAIVED, subject to the terms and conditions of the this certificate does not confer rights to the certificate holder In lieu of such PRODUCER V & V Insurance Agency Inc Po Box 159 ' Cresco IA 52136 INSURED SNO HAWKS INC 5912 ASTER LANE WATERLOO IA 50701 AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED pollcy(lec) must have ADDITIONAL INSURED provisions or be endorsed. policy, certain policies may require an endorsement A statement on endorsemen . 9). r'TTNAKE.. T -- - PHONE ` Dale -547VagtFAX t H E €*q 563-547 2161 lA� No) 563-547 2046 E Mat . Insuranceevandvin5 Com ADDRESS;. ._....,,, .. INBUREKED AFFORDING COVERAGE.._ ... INSURERA; Dakota Fire Insurance CO .......... ;.10863 INSURER -B INsuRRc INSURER .o MSURERE INSt1RERF:._, .. ......... ...... ... _ .:.. • • THIS INDICATED. CERTIFICATE EXCLUSIONS INSRi ice__ X • A IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. • TYPE OF INSURANCE Obi: SUER ..._... :w'POLICY EFF ! POLicY LIMITS E :�'ia, POLICY NUMBER '. � COMMERCIAL GENERAL LWBWTY x ._..__, CLAIMS -MADE ...� OCCUR NLAGGRE 13ATEOMIT APPLIES PER: PRO- kJ'..1,:Y JECT E J LOC 4D78753 ._ 10/01/2016 EACHoccuRRENCE `"; 1,000,000 DAMAGE 70 HEf T b -: ...-.. .... , PRFnA S—ES (Fa 0rxtmenee1 5 0 MED E%P (V!Y cme person) L 10/01/2017 PERSONAL B ADV INJURY $ 00 GENERAL AGGREGATE $ 1,000,000 PRODUCTS - COMP/OP AGG $ 0 C(. �tEpl>tnh:L,gtiter BODILY INJURY (Per parson) $ BODILY INJURY (Per acadanqY• _. . PRCA ERt Y OAFAACX: S e, rc-er+'+PJ,l14.._:.... ' $ , AUTOMOBILE UABW7Y ANY AUTO OWNED : AUTOS ONLY HIRED I AUTOS ONLY .`__.-. � SCHEDULED -- AUTOS NON -OWNED AUTOS ONLY - - UMBRELLA LIAR - OCCUR _ .... _ _ , cm EXCESS LIAR &DE .:.._._. __.._;.__ .:�.:. DEO - RETENTION ... -:.--. EACH OCCURRENCE $ AGGREGATE WORKERS COMPENSATION AND EMPLOYERS' UABILITY YIN ANYPROPRIETORIPARTNER/EXECUTnVEl OFFICERANEMBER EXCLUDED? I (pya�ndatony In NK) OF,SGrRIPTION OF OPERATIONS below NIA -- - -_.. _. ' - PER STATUTE" EL EACH ACCIDENT 3, E L DISEASE. EA EMPLOYEE- $ E L DISEASE -POLICY LIMIT 13 ---- ..... DES CRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached H more space la required) Snowmobile Club and Trail Liability Insurance, including liability coverage for (2) groomers and (1) ATV (used for trail maintenance only). Additional insured for trail usage: City of Janesville, 227 Main Street, Janesville IA 50847; Five Star Snow Trails Assn, 5912 Aster Lane, Waterloo IA 50701; The State of Iowa & All of its Political Subdivisions, Wallace State Office Building, Des Moines IA 50319. See attached form CG7501 regarding contracted landowners for trail usage. Premise liability coverage is Excluded on this policy: TE' HOLDER ANCELLAT1ON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE • ACORD 25 (2016/03) ,i. ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION - VICARIOUS LIABILITY This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): ALL STATE SNOWMOBILE ASSOCIATION AND SNOWMOBILE CLUB DESIGNATED TRAIL LANDOWNERS FOR USE OF LAND FOR SNOWMOBILE TRAIL USAGE ONLY. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section Who Is An Insured is amended to in- clude as an additional insured the person(s) or organtation(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property dam- ageor "personal and advertising injury" caused, in whole, by your acts or omissions or the acts or omis- sions of those acting on your behalf: 1. In the performance of your ongoing operations; Or 2. In connection with your premises owned by or rented to you. However, the Insurance afforded to such additional insured only applies to the extent permitted by law. B. This insurance does not apply to any "bodily Injury", "property damage" or "personal and advertising in- jury" resulting from any act or omission by, or willful misconduct of the additional insured shown in the Schedule, whether the sole or a contributing cause of the loss. The coverage afforded to the additional insured is limited solely to the additional insured's "vicarious liability" that is a specific and direct result of your conduct. "Vicarious liability" as used in this endorsement means liability that is imposed on the additional in- sured solely by virtue of its relationship with you, and not due to any act or omission of the additional in- sured. C. With respect to the insurance afforded to these ad- ditional insureds, the following is added to Section — Limits Of Insurance: If coverage provided to the additional insured is re- quired by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insur- ance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. 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