APPLICATION FOR EXCAVATION AND STREET OPENING PERMIT

I. Applicant Information

Applicant Name*

Title

Project Location*

Project Start Date

Project Completion Date*

Reason for Street Opening*

II. Contractor Information

Compant Name*

Contact Person*

Phone*

Address*

Applicant’s Federal or State EIN*

III. Project Information

Type of pavement*

Base and thickness, if known

Distance (in feet) from center line of road to gutter or ditch*

Distance (in feet) from center line of road to right-of-way*

Nearest distance (in feet) from center of road to any structure*

Length (in feet) of trench work along the road*

Width (in feet) of trench along the road*

Approximate area of opening in improved surface (in square yards)*

Approximate area of opening in unimproved surface (in square yards)*

Depth (in feet) of trench below the surface*

IV. Workers Compensation Insurance Information

Check all that apply.*

Certificate of Insurance will be attached with application

Certificate of Self Insurance will be attached with application

Applicant owns the property

Applicant does not own the property

Contractor/applicant is a sole proprietorship without employees

Contractor/applicant is a corporation, and the only employees

Contractor/applicant is a corporation and the only employees working on the project have and are qualified as “Executive Employees” under Section 104 of the Workers’ Compensation Act.

All of the contractor/applicant’s employees on the project are exempt on religious grounds under Section 304.2 of the Workers Compensation Act.

Other (explain below)

Certificate of Insurance

Max. file size: 256 MB.

Certificate of Self Insurance

Max. file size: 256 MB.

Explain 'other'*

This policy provides coverage for the requirements of the Workers Compensation Act, the Occupational Disease Act, and where applicable, the Federal Long Shore and Harbor’s Worker’s Compensation Act.
The insurer has been notified that the municipality issuing the permit, the Borough of Verona is to be named a policy certificate holder.
Any subcontractors used on this project shall be required to carry their own worker’s compensation insurance coverage.
The contractor/policyholder shall notify the Borough of Verona of any change in status, cancellation or expiration of the worker’s compensation coverage.
Violation of the Worker’s Compensation Act or the terms of this permit shall subject the
contractor/policyholder to a stop-work order and other fines and penalties as provided by law.
The application is not permitted to employ any individual to perform work on this project pursuant to the permit in violation of the Act.

V. Applicant Signature

Electronic Signature*

Please type your full name above to serve as your electronic signature.

IV. Payment & Application Submission Information

Under and subject to all the conditions, restrictions and regulations prescribed by the Borough of Verona and on the general provisions and specifications, a true copy whereof is attached and made a part hereof, with the same force and effect as if written or printed herein and under and subject to the special conditions, restrictions and regulations hereinafter set force. The Borough is to be named insured on the certificate of insurance.

Non-Refundable Application Fee

Price:

Inspection Fee (due with application)

Price:

Total fee due

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Borough Office

I. Applicant Information

II. Contractor Information

III. Project Information

IV. Workers Compensation Insurance Information

V. Applicant Signature

IV. Payment & Application Submission Information

Municipal Office

Office Hours

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