<p> NW Region Utilities Office Permit and Franchise Section</p><p>Application for Utility Permit or Franchise Checklist</p><p>Permit/Franchise No.: Applicant: Date: </p><p>Instructions Please provide the required information indicated by the checked boxes below. The bold words correspond to individual boxes on the Application for Utility Permit or Franchise form. Until the indicated information is provided, we will be unable to complete the processing and approval of your application. If you have any question please contact the WSDOT NW Region Utility Office at (206) 440- 4430.</p><p>Application Fees This application is categorized as indicated below. Please provide the appropriate fee payment as shown: Category 1 $500.00 Franchise Consolidation $300.00 Category 2 $300.00 Franchise Renewal $250.00 Category 3 $150.00</p><p>Our records indicate you have paid $ to date. Please provide the remaining Application Fee in the amount of $ You have overpaid the Application Fee. You are due a refund of $ </p><p>Description and Location Indicate State Route1 (SR) number (the highway the proposed utility is to be constructed on). Indicate (at/from) Milepost1 number to a minimum of 1/10th of a mile (the point where your proposed utility will begin). Indicate to Milepost1 number to a minimum of 1/10th of a mile (the point where your proposed utility will end). Provide the name of the County on in County,. </p><p>If marked below, provide Section, Township, and Range information to the nearest Quarter, Quarter, (i.e., SW qtr, NW qtr). This information is available from a variety of sources. There may be attached a WSDOT right of way map for your use. Provide Quarter, Quarter information on the to begin in the line, that your proposed utility will begin in. The information on this line should be to the nearest Quarter, Quarter (i.e. SW ¼ of the NW ¼). Provide the Section information on the Section line that your proposed utility will begin. Provide the Township information on Township line that your proposed utility will begin. Provide the Township information on Range line that your proposed utility will begin. </p><p>1 Please note that WSDOT locates all utilities within its Right of Way by the SR and MP of the highway the utility is located on. This information must be on the application for approval. Project stationing is not acceptable. 1 1</p><p>Page 1 of 3 NW Region Utilities Office Permit and Franchise Section</p><p>Provide Quarter, Quarter information on the to end in the line, that your proposed utility will end. The information on this line should be to the nearest Quarter, Quarter (i.e. SW ¼ of the NW ¼). Provide the Section information on the Section line that your proposed utility will end. Provide the Township information on Township line that your proposed utility will end. Provide the Township information on Range line that your proposed utility will end. </p><p>Additional Costs Please read the information located near the middle of the Application for General Permit regarding basic fees and additional costs. Based on this statement, if there is a check in the box below, we anticipate there will be additional costs incurred that are associated with the processing of your application. Attached for your signature is a billable account application between you and/or your company and WSDOT, referred to as a JA Account. Please sign and date this application, and forward it to this office. We will establish an account in your name or the name of the company you represent. As stated above, this application is needed to help defray any additional costs for reviews, approvals, or other work relating to your application. Failure to promptly forward this JA Account application will delay approval of your application. </p><p>Applicant Information and Signature The applicant information check below must be for the owner of the utility. Anyone can apply for a utility permit or franchise on behalf of the utility owner, such as a consultant or contractor, but applicant information, including the signature, must be of and by the owner or authorized agent. Provide the name of the Applicant (Referred to as Utility). Provide utility Address. Provide Utility City, State, and Zip Code. Provide Utility Telephone contact number. Provided for your convenience is a space for an Applicant Reference (WO) Number you may wish to use. If provided, WSDOT will use this number on correspondence to applicants for applicant identification purposes. Provide Applicant Authorized Signature. This signature must be by an officer or other designated person of the utility owner. Consultants, contractors, or sub-contractors are not considered authorized signatures. Using a signature other than is authorized will be cause for rejection of the application and could cause undue delay in the application process. As requested, please Print or Type Name of authorized signatory. Provide Title of utility authorized signatory. Provide signature date on the Dated this day of , line. Provide tax ID or Personal SSN on the Federal Tax ID Number or Social Security Number line. </p><p>The reminder of the application is for WSDOT use only. Please do not place any information in the two boxes at the bottom of the page. In the Exhibits Attached box, WSDOT will index any attachments or exhibits associated with the approved permit or franchise. </p><p>Page 2 of 3 NW Region Utilities Office Permit and Franchise Section</p><p>Other Permitting Requirements</p><p>Surety Bonding In addition to completing the required forms, WAC 468-34-020 states the Department of Transportation cannot authorize any work to be done on WSDOT right-of-way until a surety bond has been posted for the utility installation being applied for. There are three methods of bonding that are acceptable. These are listed below. Our records indicate that you are not on our Blanket Bond List and therefore must provide . Please provide one of the following sureties:</p><p>Provide an Individual Bond An Individual Bond is for a single utility installation. Must be held for one year after conclusion of your utility installation, at which time it can be released upon written request. Minimum $1,000 bond, but more may be required based on the type and circumstances of installation. Use DOT form 224-048. Provide an Assignment of Account/Certificate of Deposit. Similar to an Individual Bond, but maintained by a bank of your choice. Used for single utility installations. Minimum $1,000 balance, but more may be required based on the type and circumstances of installation. Provide a Blanket Bond. A Blanket Bond can be used for more than one installation. This method is recommended for utilities planning to do multiple utility installations on WSDOT right of way. Minimum $10,000 bond. Use DOT form 224-012. </p><p>Traffic Control Plan Please provide a detailed site-specific Traffic Control Plan (TCP). This plan should include the location of the work zone, traffic control devices to be used and their placement in relation to the work zone, cone spacing, taper lengths, advance warning sign placement and spacing, lane closures, flagger positions, et cetera. Generic plans are not acceptable and will be subject to rejection. </p><p>General Comments</p><p>Page 3 of 3</p>