APPENDIX C FORMS. Table of Content

Transcription

1 APPENDIX C FORMS Table of Content Description OUC Submittal Notice Form Required Form of Letter of Credit for Chapter License Required Form of Letter of Credit for Chapter Permittee Application For Work in the Public Way License Subdivision / Dedication Application Duty to Build Agreement

2 CHICAGO DEPARTMENT OF TRANSPORTATION DIVISION OF INFRASTRUCTURE MANAGEMENT OFFICE OF UNDERGROUND COORDINATION 121 NORTH LASALLE STREET ROOM 905 CHICAGO, ILLINOIS Permittee Information NOTICE FORM Permittee Name: Phone Number: Company Name: Current Address: Is Permittee a telecommunications provider: Yes No Registration No.: 2. Is the Permit for another Company/Person for whom the work will be done? Retailer: Yes No Yes, if yes fill out information below No Company/Person Name: Phone Number: Company/Person Address: Is the company a telecommunications provider? Yes No Registration No.: Retailer: Yes No 3. Purpose of Review Information Retrieval Existing Facility Protection 4. Scope of Work Describe Briefly: 5. Manhole Installations Are manhole/handhole installations planned in the public way: Yes (see requirements under Chapter 10) No 6. Construction Document Submittal (One (1) Disc with CADD Drawings Published in DWF Format) Yes No If not, explain: 7. Location of Work Work Location Description: Legal Address: Any installation in the tunnels: Yes No If yes, contact the Division of Engineering at (312) for information and permitting requirements. Signature Date Permittee Signature

3 (Date) BENEFICIARY Required Form Of Letter Of Credit For Chapter License City of Chicago c/o Department of Transportation 121 North La Salle Street Room 905 Chicago, Illinois Gentlemen: IRREVOCABLE STANDBY LETTER OF CREDIT APPLICANT [name of licensee] We hereby issue Irrevocable Standby Letter of Credit No. ( Credit ) in favor of the City of Chicago for the account of [name of licensee] up to the aggregate amount of Dollars ($ ), effective immediately. This Credit is issued, presentable and payable at our offices at, Attention:, and expires at Chicago time on [date]. Funds under this Credit are available to you unconditionally against your notarized sight drafts for any sum or sums not exceeding a total of Dollars ($ ) drawn on us mentioning the Credit by number and signed by the Commissioner of Transportation of the City of Chicago or the City Comptroller of the City of Chicago (whether acting or actual). Funds drawn under this Credit shall be paid in the form of a check made payable to City of Chicago and shall be sent by overnight delivery to the City of Chicago at the address listed above. Partial and multiple drawings are permitted. This Credit sets forth in full the terms of our undertaking, and may be amended only by a written amendment signed by us and by the beneficiary. Our obligations hereunder are primary obligations to the City of Chicago. We hereby engage with you: we will honor drafts drawn and presented under and in compliance with the terms of this Credit. This Credit is subject to the Uniform Customs and Practice for Documentary Credits, International Chamber of Commerce Publication No. 500, 1993 revision ( UCP ) and to the Uniform Commercial Code - Letters of Credit, 810 ILCS 5/5-101et seq., as amended, as in effect in the State of Illinois ( UCC ). To the extent the provisions of the UCP and the UCC conflict, the provisions of the UCC shall control. Name of Issuing Institution By: (signature) Name: Title:

4 (Date) BENEFICIARY Required Form of Letter of Credit for Chapter Permittee City of Chicago c/o Department of Transportation 121 North La Salle Street Room 905 Chicago, Illinois Gentlemen: IRREVOCABLE STANDBY LETTER OF CREDIT APPLICANT [name of permittee] We hereby issue Irrevocable Standby Letter of Credit No. ( Credit ) in favor of the City of Chicago for the account of [name of permittee] up to the aggregate amount of Dollars ($ ), effective immediately. This Credit is issued, presentable and payable at our offices at, Attention:, and expires at Chicago time on (date). Funds under this Credit are available to you unconditionally against your notarized sight drafts for any sum or sums not exceeding a total of Dollars ($ ) drawn on us mentioning the Credit by number and signed by the Commissioner of Transportation of the City of Chicago or the City Comptroller of the City of Chicago (whether acting or actual). Funds drawn under this Credit shall be paid in the form of a check made payable to City of Chicago and shall be sent by overnight delivery to the City of Chicago at the address listed above. Partial and multiple drawings are permitted. This Credit sets forth in full the terms of our undertaking, and may be amended only by a written amendment signed by us and by the beneficiary. Our obligations hereunder are primary obligations to the City of Chicago. We hereby engage with you we will honor drafts drawn and presented under and in compliance with the terms of this Credit. This expiry of this Credit will be deemed to be automatically extended without amendment for one year from the expiry date hereof, or any future expiration date, unless at least 30 days before the most imminent anniversary of the date of issuance of this Credit, we notify the Commissioner of the Department of Transportation of the City of Chicago, at the address listed above, by overnight delivery service or courier, that we will not extend the expiry of this Credit for any such additional period. This Credit is subject to the Uniform Customs and Practice for Documentary Credits, International Chamber of Commerce Publication No. 500, 1993 revision ( UCP ) and to the Uniform Commercial Code - Letters of Credit, 810 ILCS 5/5-101 et seq., as amended, as in effect in the State of Illinois ( UCC ). To the extent the provisions of the UCP and the UCC conflict, the provisions of the UCC shall control. Name of Issuing Institution By: (signature) Name: Title:

5 APPLICATION PUBLIC WAY WORK LICENSE 1. Name: F.E.I.N. #: Contractor: S.S. #: Individual: Tax ID #: 2. Address: Street: City: State: Zip: Telephone #: Fax #: If renewal of existing license and none of the following information has changed, skip to next box. 3. Company Ownership (25% or more / or largest % of ownership) A. Name: % of Ownership B. Name: % of Ownership C. Name: % of Ownership D. Name: % of Ownership 1. Level of Letter of Credit Provided $5, $25, $50, $100, Letter of Credit expiration date: 2. Certificate of Insurance Provided Policy # Insurance Carrier: Expiration Date: 6. Application Information I agree to indemnify, save and keep harmless the City of Chicago from any and all loss, cost, damage, expense of liability of any kind whatsoever which the City may suffer, or which the City may be put to, or which may be recovered from the City, from or on account of the issuance of this license, or from or on account of any act or thing done be virtue of the authority given in this license, or for any damage, loss or expense to any person caused by the tearing up, constructing, repairing or removing of such public way or part thereof, whether or not performed pursuant to a valid license. Applicant Name: Application Date: Applicant Signature: 7. Additional Information: Name(s) of persons authorized to draw or cancel permits in the Company Name: Emergency Contact Name and Telephone Numbers: Name: Cell phone: Fax #: Pager:

6 Instructions: This below document must be reproduced on the applicant's letterhead, executed, and notarized: SUBDIVISION / DEDICATION APPLICATION DUTY TO BUILD AGREEMENT (Must be completed by the applicant, not their attorney) In support of my current application with the Chicago Department of Transportation's Maps and Plats unit, for a subdivision/dedication of my private property, I hereby state that I am the applicant or the company agent for the applicant company involved in the project, and that I have the authority to agree to the below terms of the Subdivision. Please initial: I am aware that I am responsible for the construction of all public and private rights of way (streets, alleys, etc) described on the Plat of Subdivision/Dedication. 1 further understand that all rights of way (both public and private) must be built to City specifications as detailed in CDOT's Regulation for Openings. Construction and Repair in the Public Way. Lastly, I understand that construction deposits will be required to assure that the work is done correctly. An inspection will be conducted by the City upon completion of the work. The City of Chicago reserves the right to require demolition and reinstallation of any facilities that are judged to be sub par or that do not adhere to the City's standards. Signed: Date: Printed name: Title: Organization: Address: Zip: Phone/fax: / Notary: Revised 03/12/07