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2. This application is for construction that passes through or inside of the public right-of-way. This permit is NOT required for the installation or replacement of a driveway or other culvert that is currently subject to review by the Delaware County Engineer's Office.

4. This section is for use by Liberty Township ONLY
10. APPLICANT INFORMATION
12. Job Order Number (optional)
14. Applicant Name*
15. Applicant Email Address*
17. Address - Street, City, State, Zip*
19. Email Address*
20. Applicant Phone Number*
22. 24 Hour Contact Name*
23. Phone Number*
25. LOCATION OF EXCAVATION/CONSTRUCTION SITE
27. REQUIRED: Location map showing exact location of site
29. Address - Street, City, State, Zip (if no address answer with nearest intersection)*
31. Subdivision (if applicable)
32. Delaware County Parcel ID Number (PIN)
34. Nature of excavation/summary of proposed work*
36. Estimated Construction Start Date *
    Estimated Construction Start Date
37. Estimated Construction Completion Date*
    Estimated Construction Completion Date
39. MAIN POINT OF CONTACT/EMERGENCY CONTACT
41. Name and Title*
42. Telephone Number*
44. Address - Street, City, State, Zip*
46. CONTRACTORS

    The Applicant is REQUIRED to provide the following information for any contractor which will be performing any part of the proposed work.  If more than one contractor will be used, upload a list which includes Contractor Name, Primary Point of Contact, Secondary Point of Contact, Address, Telephone, E-Mail Address, and Detail of Work Being Performed 

48. Contractor Business Name*
49. E-Mail Address*
51. Primary Contact Person*
52. Telephone Number*
54. Address - Street, City, State, Zip*
56. Secondary Contact Person*
57. Telephone Number*
59. Work being performed*
61. Upload additional Contractor Information here
63. Electronic Signature Agreement*

    I acknowledge that I have read the Liberty Township Right-of-Way Rules & Regulations and that any and all contractors assigned to perform work on this project have received and read the Liberty Township Right-of-Way Excavation Rules & Regulations.

    1. I agree.
65. Liberty Township Right-of-Way Rules & Regulations
    Liberty Township ROW Rules & Regulations
67. Electronic Signature*
69. Electronic Signature Agreement*

    Applicant acknowledges they have read the Liberty Township Right-of-Way Excavation Rules & Regulations and agrees to be bound by such regulations and the terms and conditions contained in this application.

    Applicant agrees to provide the following:

    1) Applicant agrees to provide and place such warning devices as are necessary to protect travelers on the road and to ensure their safety.

    2) Applicant agrees to complete all work to be performed under this application as soon as reasonably possible and to completely restore the entire road right-of-way to the condition that existed before such work was undertaken, in accordance with the Liberty Township Right-of-Way Excavation Rules & Regulations.

    3) Applicant agrees to notify Liberty Township staff, the Liberty Township Fire Department, and all applicable utility providers of the right-of-way excavation and to to obtain all required permits prior to the commencement of any work or excavation in the road right-of-way. Further, the applicant agrees to provide copies of any such required permits to Liberty Township.

    4) Applicant agrees to indemnify and hold harmless Liberty Township, its Board of Trustees, and all officers, employees, and agents of Liberty Township, for any loss, cost, liability, damage, claim, demand, or cause of action arising from, under or connected with, the excavation and work covered by this application, and has properly executed the attached indemnification and hold harmless agreement.

    Applicant is REQUIRED to complete and sign an "Indemnification and Hold Harmless Agreement"  which will be sent to the Applicant via an electronic signature program, e.g., DocuSign, upon acceptance of the Application by Liberty Township.

    5) The Applicant agrees to pay a $50.00 fee (ORC 5571.16), which will be invoiced upon receipt of this application. Applicant also agrees to pay for all costs incurred by Liberty Township to review plans submitted by the applicant and for any inspection activities associated with this application, which will be invoiced upon completion of the Application Review. The Permit will be issued upon payment of all associated fees by Applicant.

    6)  A list of materials to be used is uploaded with this Application.

    7) The Applicant's proposed contractor(s) is/are identified in this Application. If more than one Contractor, additional contractor information has been uploaded with this Application.

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
71. Electronic Signature*
73. BOND REQUIRED*

    1. If open-cutting pavement, $150 per square yard of pavement to be cut with a minimum bond of $500.00.
    2. If working in right-of-way but outside of pavement, $100 per linear foot of work area length.
    3. If setting new poles for utilities, $50 per pole.

    Security bonds shall not be refundable if it has been determined by inspection that the applicant has not met all conditions, standards, and requirements contained in this application and in the Liberty Township Right-of-Way Excavation Rules & Regulations. It is the responsibility of the Applicant to notify Liberty Township when ready for inspection. No refund will be granted until inspection has taken place and it has been determined by the responsible Liberty Township official that the work has been completed to the required standards.

    Persons failing to comply with the standards and regulations, or failing to obtain a permit, shall be notified in writing by Liberty Township that they have 30 days from the date of notification to eliminate the violation and return the right-of-way to its original condition.

    Persons failing to come into compliance within the 30-day period will forfeit their bond and may be prosecuted pursuant to Section 5571.99 of the Ohio Revised Code. The Liberty Township Trustees will recommend to the Court that violators be ordered to eliminate the violation at the violator's expense; or that the Court appoint a qualified company to remove the violation, and the costs of same be placed on the tax duplicate as lien, to be collected with their taxes.

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
75. Electronic Signature*
76. Date Signed*
    Date Signed
78. Printed Name*
79. Title*
Leave This Blank:


83. 1. Receive an email copy of this form.
84. Email address

    This field is not part of the form submission.

85. Submit

* indicates a required field