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HomeMy WebLinkAboutSnowmobile Trail ApplicationL,IOWADOT Fort, 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 04/15/18 APPLICANT E NDI'VIDUAL 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 Range (SEE ATTACHED LISTING) on Highway No. , Twp. (SEE ATTACHED LISTING) 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, Md., Last- Print or Type) Tony D. French Applicant Catur� e,(HaP SIV —rJlF— L"Sw��J � of ate 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 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) n Recommend Approval 0 Do Not Recommend Approval n None Required Authorized FHWA Representative Signature Date (DOT Final Action and Agreements on next page) Page 1 of 2 DEPARTMENT OF TRANSPORTATION FINAL ACTION ED Application Approved 0 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 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 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 all 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 shalt reimburse the Iowa Department of Transportation for any materials removed from the highway right-of-way described as follows: 16. The following special requirements shall apply to this permit: PLEASE NOTE: The sponsor agrees to hold harmless the State of Iowa and the Iowa 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 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 Title Date Type or Print Name Authorized Official for the City of WATERLOO 3A 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. 7. Crossing of US 218 at East Schrock Road, milepost 173.74. Marked, "groomed" trail along both ditches of US milepost 173.74 to LaPorte City north city limits. 8. This item was completely removed and the number balance of items. 9. This item was completely removed and the number balance of items. 10. This item was completely removed and the number balance of items. * 11. This item was completely removed and the number balance of items. 12. This item was completely removed and the number balance of items. 4 Black Hawk County-2017.docx 218 from East Schrock Road, retained to avoid renumbering retained to avoid renumbering retained to avoid renumbering retained to avoid renumbering retained to avoid renumbering 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) * This item was completely deleted due to re construction of the interchange of US 218 and County Road C57. There is no longer snowmobile access to that area. Balance of items are the same as shown on the 2016 application. 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 Sno Hawks, Inc. 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-2017.docx ACO ES° CERTIFICATE OF LIABILITY INSURANCE DATElMMIODEr 1'r 10/03/2010" THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. 711IS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT; If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed, If SUBROGATION IS WAIVED, subject to the terrns and conditions of the policy, certain policies may require an endorsement. A statement on this certificat . does not confer rights to the certificate holder in lieu or such endorsement(s) PRODUCER --. I i,,jr' I Dale \:01 0:!. V &j V Insurance Agency IPTG !HORN e 11 563-547-2161 Po Box 159 r A,I II15Ufa'u 1 z)v�ul Crgsco IA 52136 II:S'11RED SVO HAWKS INC 5912 ASTER LANE WATERLOO IA 50701 INSURER'S' AFFORDING COVERAGE INSURER A: Dakota Fire Insurance Co. INsu0FR R r INSURER () INSURER E: iFm Nn): 563547-2046 1./010 10863 1 INSURER R: TIFICATE BER: COVERAGES THISISTO CE Tin,' THAT ECANY EEO INSURANCE LISTED OR CONDITION BE N ifl REVISIONEBOMBER: .a 71PY THAT THE POLICIES OF INSURANCC BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. N NDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AOL SLIER POLICY 000 POLICY EXP ITR TY YY PE OF INSURANCE _._/Nqn VOID POLICY NUMBER iRMIDDIYYj IMMInprYTYW /MOTS X COMMER CIAL GENERAL LIABILITY 6hf. I RCCMIRRENGE 1,000,000 DAMAGE 10 105011110 X Cl AII.18-15'0 6 OCCUR n rS," nr.., 0 INEDEXP1.014o 0070051 0 A 4078753 10/01/2016 10/01/2017 Ilr A nA 11. 0 L.InIAPPUES 660- ( LOC nrla; AIITOMOBILE'•IAaILITY ANY AUTO, OWNED I SCHEDULED .013705 ONLY 0E1706 NIFEG NON -OWNED 00705 ONLY A71105 0007 UM0RELIIA LIAE EXCESS IIAB OED 0E1E013007. WORKERS COMPENSATION ANDEMPLOYERS' RILT [Y IN ANYP000RIEX030ARTNER/EXECUTIVE OFFICER/MEMEREXCLUDED? (Mandatory In 11) 'I%Es, 1155040 ) DESCRIPTIONN 0 OF OPERATIONS h2ILt1 000:00 00700-0006 NIA 117 _-.01_.+0,0,000/5111 _ 1,000,000 z )- 0 comprop ADE 0 911:10000000NNU0 57.53 REGATE L1100170CCIDE61 I. DISEASE - EA 00500701 DESCRIPTION OF OPERATIONS /LOCATIONS / VEHICLES IAGORD 101, Additional Rernilk... hed le, mny he altoci,ed f no.,. spvice srequ Tedi Snowmobile,IClub 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 50647; 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. Preni'lise liability coverage is Excluded on this policy CFRTlFICfirE- iOLDFR ACORD 25 (2016/03) ANGELI.ATI0N SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 010 111151101/0/00:110 ©1e88-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo a e registered marks of ACORD COMMERCIAL GENERAL, i_IA IE I'('Y, THIS ENDORSEMENT CHANGES THE PC)EASE READ Fr CAREFULLY UIl IONAL INSURED - DESIGNATED PERSON OR ORGANIZATION VICARIOUS LIABILITY This endorsement modifies insurance provided under the following• COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Narnq Of Additional tnsured Person(s) Or {:trganization(s): ALL TATE SNOVVMOE,ILE ASSOCIATION AND SNOWMOBILE CLUE) DESIGNATED TRAIL LANDOWNERS • • FOR USE OF LAND FOR SNOWMOBILE TRAIL USAGE ONLY, • Inrequired to complete this Schedule, if not A. Section 11 -- Who Is Are Insured is amended to in- clude as an additional insured the person(s) Or organization(s) shown in the Schedule, but only with resppct to liability for "bodily injury", "property dam- age", or "personal and advertising injury" caused, in vvhole, by your acts or omissions or the acts Or Oi ii3- sion1 of those acting on your behalf: 1, n'the performance of your ongoing operations; Qr 2. in connection with your premises owned by or tented to you. however, the insurance afforded to such additional insued only applies to the extent permitted by law. ted. This insurance does not apply to any "bodily injury", "property damage" or "personal and advertising in- jury" i 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 insi.uted is limited solely to the additional insureds "vicarious liability" that is a specific and direct result of yciur conduct. 057501(10-13) Includes cupyrrghted rnaterial of I wn above, will be shown in the Declarations. outs liability" as used in this endorsement means liability that is imposed en 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. 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 al insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insur- snce shown in the Declarations; whichever is less. This endorsement shall not increase the radalllicabhs Limits of Insurance shown in the Declarations. Praperiies, Inc, with its permission. Page 1 o CLUB NAME: SNO HAWKS, INC. LANDOWNERS AS ADDITIONAL INSURED FOR CLUB CONTRACTED TRAIL USAGE ONLY City of Janesville Iowa 227 Main Street Janesville, IA 50647 The State of Iowa & All of its political Subdivisions Wallace State Office Building Des Moines, IA 50319 Five Star Snow Trails Association 5912 Aster Lane Waterloo, IA 50701 Page 1 of 1