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HomeMy WebLinkAboutIowa Department of Transportation-10/17/2016 (2)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 3203 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 Trait 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.ii 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 an account of the conditions and requirements of this agreement. Applicant Name (First, M.I., Last - Print or Type) Tony D. French Applicant Signature (ianeWiften) Date 6720 r 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 ❑ Do Not Recommend Approval ❑ None Required Handwritten Signature Title Date Type or Print Name (SEE 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) fl Recommend Approval Do Not Recommend Approval Q None Required Authorized FHWA Representative Signature Date (DOT Final Action and Agreements on next page) Page 1 of 2 DEPARTMENT OF TRANSPORTATION FINAL ACTION IK Application Approved Q Application Denied Authorized Highway District Representative Daryl Erickson, EOT Permit Number. %_ Loge S 4ignAlkiewr ife ��• g4,444,...6.. 4, "w-- _ - s Notice or intention to comre nce activities on the highway rights-of-way shall be submitted by the applicant a minimum of 48 hours prior to acluatiy coninientitig the eilivitiei as herein granted by this approved application. Notice 1st) be given to the • Date 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 govern. 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 lowa 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 agenciesaand employeerefroneanyenal all eauses.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 lowa 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. -1 This pemnt 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 Iowa Department of Transportation for any materials removed from the highway right-of-way described as follows: 161 The following special requirements shalt apply to this permit 'LEASE NOTE: The sponsor a erees to hold harmless the State of Iowa and the lowa Department of Transportation and to indemnify 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 furnished 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 furnished is public information and copies may be provided to the public upon request. Page 2 of 2 28 November 2016 City of Waterloo ATTN: City Clerk 715 Mulberry Street Waterloo, Iowa FIVE STAR SNOW TRAILS ASSOCIATION, INC. 2202 Minnetonka Drive, Cedar Falls, IA, 50613-1522 Ph: 319-266-2929(H) • 319-610-1171(C) ♦ Email: frenchtdl(dWahoo.com Enclosed is the final approved copy of the Iowa Department of Transportation Form 810028, requesting a permit to establish & maintain a snowmobile trail within the right of way of State Highways. A portion of that trail resides within the city limits of Waterloo. Previously you received a packet of documents from our office that contained a letter of instructions, a temporary unapproved copy of DOT Form 810028, a blank copy of the special "City Action Form", a listing showing all of the locations along the trail where it impacts DOT property and a copy of the Certificate of Liability Insurance indicating coverage for the City of Waterloo as an Additional Insured. These documents formed your "Temporary" Permit which you should have on file. You should now remove the "Temporary" DOT Form 810028 and replace it with the enclosed Final approved copy showing the Permit number near the top of page 1 and signed on page 2 by a representative of the DOT and a copy of an email from Darly Erickson, the DOT repesentative. When the above actiion is completed, your " Temporary" file becomes the Permanent Approved Permit. Please note the special comments on the above mentioned email. If you have any questions or comments, you may contact me by phone at: 319-266-2929. If that phone goes to "voice mail", please try: 319-610-1171. If that phone goes to voice mail, please leave a message and I will return your call as soon as possible. You may also send an email to: frenchtd1@yahoo.com. Thank you. Ton yi rench Administrative Assistant umbra damelick@cfu.net Snowmobile Permit From : Erickson, Daryl <Daryl.Erickson@iowadot.us> Subject : Snowmobile Permit To : DAMELICK@CFU.NET Cc : Thede, Bany <Barry.Thede@iowadot.us>, Siems, Kip <Kip.Siems@iowadot.us>, Dietz, Don <Don.Dietz@iowadot.us>, Federspiel, William <William.Federspiel@iowadot.us>, Wright, Richard <Richard.Wright@iowadot.us> Dick, Tue, Nov 15, 2016 10:45 AM 1 attachment Attached is your approved Work Within State Highway Right -Of -Way permit for snowmobile trails in Black Hawk County Please contact Barry Thede, Waterloo garage supervisor, at (319)-233-3055 prior to starting work so he is aware of work along the highway right-of-way. The permit expiration/completion date is 4/15/17. Please have ALL trail signs removed by expiration date. If you should have any questions, please contact me. LY2i46 tricrison t 3 O Y 2: `,e3rd Street �� a =`sari A Itr" v.g nrad 50'4 �D s -- 5 Star Trails Snowmobile Permit-1.pdf 2 MB