BOROUGH OF ST. CLAIR 16 S. Third Street, St. Clair,PA 17970 Phone: (570)4 429-0640 Fax: (570) 429-2829 APPLICATION FOR ROAD OPENING PERMIT I. APPLICANTS NAME: TELEPHONE # CONTACT PERSON: TELEPHONE #: ADDRESS: 2. EXCAVATORS NAME: TELEPHONE #: ADDRESS: INSURANCE CARRIER: POLICY #: 3. PURPOSE OF EXCAVATION: 4. LOCATION OF EXCAVATION: 5. START DATE: DAYS FOR COMPLETION: 6. DESCRIPTION OF EXCAVATION: LENGTH WIDTH DEPTH 7 METHOD OF RESTORATION: CONCRETE BITUMINOUS 8. SKETCH OF PROPOSED WORK: (Use area below or attach separate sheet) (SHOWI LOCATIONOF ROADCUT,EDGEOF PAVEMENT, EDGEOFR RIGITOFWAY.STRLET) NAME, TAATOGATSZEBSTRETNIN) the applicant as listed above execute this application this day of 20 and understand the requirements of Borough of St. Clair Ordinance Number and road restoration requirements imposed by said ordinance. SIGNATURE: DATE: BOROUGH OF ST. CLAIR, INSPECTION and CALCULATION OF FEES PERMIT FEES INSPECTIONS Permit Issuance $1 100.00 Road Cutting Method Inspection Fee Backfill Date (See Fee Schedule) Type Restoration Deposit (see note 1) Compaction Method (See Fee Schedule) Temporary Restoration Date TOTAL FEES DUE: Final Restoration Date Fees Paid (Date): Note: 1. The one year retainer fee shall apply to all street excavations within Borough Street right-of-ways. The retainer fee will be retumed to the applicant after the one year responsibility of the applicant to correct any settlement or defective work following final restoration. Ifafter one year from final restoration the excavation is unsatisfactory due to settlement or defective work, the Borough may chose to correct the excavation and deduct the cost from the retainer fec, or bill the applicant additionally, for restoration of the excavation. PREMIT NUMBER: ISSUE DATE: Approved By: Title: