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HomeMy WebLinkAboutPERMIT TO WORK WITHIN THE COUNTY RIGHT-OF-WAY COUNTY OF HAWAI‘I DEPARTMENT OF PUBLIC WORKS –ENGINEERING DIVISION Rev PERMIT TO WORK WITHIN THE COUNTY RIGHT-OF-WAY IN CONSIDERATION OFGRANTING THIS PERMIT, THE PERMITTEE UNDERSTANDSANDAGREES TO: the County, its officers, representatives, employees, andagents AGENCY USE ONLY PERMIT NO: FEE: County of Hawai‘i is an Equal Opportunity Provider and Employer DPW Form 33(2) CONSTRUCTION PERMIT CONDITIONS OF APPROVAL 48 48 5 County of Hawai‘i is an Equal Opportunity Provider and Employer Rev. 4/09/15 County of Hawaii DEPARTMENT OF PUBLIC WORKS – ENGINEERING DIVISION Permit to Work within the County Right-of-Way INSTRUCTIONS TO THE APPLICANT 1.The Applicant shall provide three (3) sets of plans to the Department of Public Works. The plans shall include the dimensions of work relative to the road and property lines, type of asphalt or concrete pavement, swales (or other drainage devices) and any other relevant information. 2.All work shall be in accordance with Chapter 22 – County Streets, of the Hawaii County Code, and as shown on the approved plans. 3.As required, all work shall be performed by a licensed contractor. The contractor may sign the permit application on behalf of the permittee/owner. 4. required, the Applicant shall provide a copy of DCAB’s “Document Review” confirmation letter with the application. A copy of DCAB’s form and associated fee schedule can be found athttp://health.hawaii.gov/dcab/files/2013/01/HRS-103-50-Transmittal-Form-Dec-2012.pdf. 5.If not already on file with the Department of Public Works, the contractor shall provide a certificate of insurance specifically naming as an additionally insured, the County, its officers, representatives, employees, and agents as required by Hawaii County Code. 6.The issued permit will become null and void if the authorized work is not completed within one (1) year of the issuance date. 7.If you are closing a road, at least two (2) weeks before the scheduled closure, complete an application form and drop it off at the Police Department’s Traffic Services. (Application Forms are available from Traffic Services 961-2227 or 961-2226). Attach a map of the area to the application. The Police Department will route the application through all applicable County agencies for approval. Countyof Hawai‘i is an Equal Opportunity Provider and Employer AL,UKU UtK I Ir II.HI C UP' LIHIJILI I T IIVJUrCHIVI�C 09/11/06 I -PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED SAM PLIE COVERAGES INSURER A 41 INSURER B: INSURER C: INSURER Cr. INSURER E: • • THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING • �:+ ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR• •: LICLL CONDITIONS MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ATHE TERMS, EXCLUSIONS AND OF SUCH � ts�' POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PMD CLAIMS. ' ?". -� •fa Mist( LTR ADD"I. INSRC TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MMIDDIYY) POLICY EXPIRATION. DATE (MM/DD/YY) _• UNITS •• • ••-` -'=- '= - . _ . A . X GENERAL LIABILITYEACH •COMMERCIAL GENERAL LIABILITY CGL5 4" 06/01/06 06/01/07 OCCURRENCE $1,000,000 X PREMISES (6a oecvrence) S 100,000 CLAIMS MADE X OCCUR MED EXP (Any one person) $5,000 PERSONAL & ADV IWURY $ 1, 000 , 000 GENERAL AGGREGATE $2,000,000 GENT. AGGREGATE LIMIT APPLIES('PER: PRODUCTS - COMP/OP AGG S 2,000,000 X j POLICY n EC ) IE1 LOC A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS CBA 63.6. 06/01/06 06/01/07 COMBINED SINGLE UMI (Ea accident) S X BODILY INJURY (Per Person) S1,000,000 — _ X BODILY INJURY (Per accident) S1,000,000 X PROPERTY DAMAGE (Per accident) S1,000,000 GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT S OTHER THAN EA ACC S AUTO ONLY: AGG S EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE S 7 OCCUR CLAIMS MADE AGGREGATE S DEDUCTIBLE RETENTION S S $ S B WORKERS COMPENSATION AND EMPLOYERS LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? K yes. describe under SPECIAL PROVISIONS below FWC'713, • 12/01/05 12/01/06 WCSIAIU- OIH- X TORY LIMITS ER EL EACH ACCIDENT $500,000 EL. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT S 500,000 OTHER • . DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL. PROVISIONS . e,, The County of Hawaii, its officers, rep=esentatives, employees and agents are named as additional insured in accordance with the General Liability '�'••• policy provisions, covering any claim or liability for damages, injuries or death resulting from any of the uses permitted hereunder CERTIFICATE HOLDER CANCELLATION County of Hawai .NOTICE Dept. of Public Works Engineering Division 101 Pauahi St Ste 7 Hilo HI 96720 - .-.Co3L • ••. ` •• • •+ .•••••.• _• r • • • �-. - •REPRESENTATIVES. •:•:•:•:•:t:•:-:•:. SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR UABIUTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORg.rp P j 4TATJYE ACORD 25 (2001/08) © ACORD CORPORATION 1988