CM-2004-016IP
1
Revised
2/8/02
APPLICATION FORM
RAILROAD PROTECTIVE LIABILITY
INSURANCE
1) Name and address of UPRR Representative:
(leave blank - to be filled in by railroad)
2) UPRR Contract Folder Number.
3) Description of. Operations: Drainage pipe & casing pipe bored crossing track
0 4) Complete Appropriate Project Information:
Pipeline/Wireline Project (fill in linear footage within Railroad Right -of -Way)
10 a) Crossing Overhead b) X Crossing Underground
® c) Longitudinal Underground d) Longitudinal Overhead
® e) Other (describe fully
OR
Other Construction Project (total project cost cannot exceed $5,000,000)
® a) Subsurface Soil/Sediment Samples b) Hand Held Auger Borings
c) Soil Gas Survey Points d) Boring Drilled w/Soil Samples
e) Temporary Piezometer Wells f) Temporary Monitoring Wells
g) Recovery Wells w/ above ground equipment h) Recovery Systems & Above Ground
Equipment
i) Other Construction Project (Describe Fully)
Total Project Cost is $
5
5) Job Location: Round Rock, Texas
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6) Start and End Dates of Work within Railroad Right-of-way 8/15/04 through 9/15/04
7) Designated Contractor To be determined (Contractor contacted is Bryant & Fry}
Mailing Address:
8) Name of involved Governmental Authority or other Contracting Party:
James R. Nuse, City Manager
Mailing Address: City of Round Rock
221 E. Main St.
Round Rock, Texas 78664
9) Cost of Railroad Protective Liability coverage for this project $ 1400.00
THIS COVERAGE WILL NOT BEGIN UNTIL THE UNION PACIFIC RAILROAD REPRESENTATIVE HAS
RECEIVED ALL (3) ITEMS SHOWN BELOW:
(1) A CHECK (in the name of Union Pacific RR) FOR THE AMOUNT QUOTED IN ITEM #9 ABOVE
(2) A CERTIFICATE OF INSURANCE EVIDENCING THE GENERAL LIABILITY COVERAGE REQUIRED
IN YOUR CONTRACT; and
(3) THIS SIGNED COMPLETED FORM.
APPLICANT'S SIGNATURE
Title:
Date: g-zii'v7'
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1014
NOTE: The corporate name of a company should be exactly as stated in its Articles of Incorporation. Type of
a Corporation, if other than a normal business corporation, MUST be shown:
City of Round Rock
4 (Municipal, quasi -municipal, body politic, etc.)
4 b) If an Individual
(Name of Individual)
APPLICATION
1). Name of Licensee: City of Round Rock
(Name to be shown on Document)
a) If a corporation:
(Exact Name of Corporation)
a corporation of the State of:
(State of Incorporation)
of
(City & State)
14) c) If an individual or corporation doing business under a trade name:
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and:
(Doing Business As or Trade Name)
d) If a partnership:
(Name of Partnership)
a partnership consisting of:
alb all of
(City & State)
2). Address of Licensee:
Public Works Department, 2008 Enterprise, Round Rock, Texas 78664
011
3). Name and mailing address of individual to whom instrument is to be sent for execution if different than shown in Item 2:
RI James R. Nuse, City Manager, 221 E. Main Street, Round Rock, Texas 78664
(Name & Address)
att 4). Billing address if different than shown in Item 2:
410 (Address)
1,1 5). Name and phone number of individual to contact in event of questions:
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Larry Madsen, Project Manager, Public Works Department, 2008 Enterprise, Round Rock, Texas 78664
Telephone: 512-218-5555 Fax # 512-218-5563
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6). a) Do you plan to utilize the right-of-way for a public use (for a utility crossing)? (X) Yes ( ) No
b) Do you have authority to utilize the right-of-way for a public use by condemnation? (X) Yes No
141- c) Will you initiate condemnation proceedings to acquire the subject property in the (X) Yes () No
/114 event negotiations are unsuccessful?
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7). When do you expect construction to begin on the Railroad Company's property? July 15, 2004
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8). When do you need to receive this agreement from the Railroad Company? May 15, 2004
(Please allow 30-45 days for crossings and 90-120 days for encroachments)
9). Permanent or Temporary emp nary Installation —Permanent
If Temporary, estimated term -
10). Location of installation - City of Round Rock, Williamson County, Texas
(City, County & State)
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100 West block of McNeil Road at Blair Avenue in City of Round Rock, Williamson County, Texas
ft. (N), (S), (E), or (W) of the (N), (S), (E), (W) or (Center) line of Section
Township N/A (N) or (S), Range N/A (E) or (W).
11) New installation, relocation or modification of existing installation which is located on the Railroad Company's property or
across tracks? New Installation
' 12). Do you have an existing agreement at this location with the Railroad Company which is to be affected by this request?
(X) No ( ) Yes, Railroad Company Contract Number:
4 13). Is installation a crossing X or encroachment or both?
14). Is installation located within a dedicated public street? No X
Yes
enclosed are records which identify and prove the dedication of such public way.
15). Additional information
pertinent to this installation: Underground Drainage Culverts are proposed to be installed via
1 boring in accordance with UPRR requirements.
16). If an encroachment, who will be served? :
(Railroad, Railroad Tenant, General Public, etc.)
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17). Did the Railroad Company's magazine advertisement affect your decision to utilize the right-of-way for a utility corridor?
( ) Yes a )No. If not, did another medium impress your decision? ( )Yes ( )No.
If applicable, please advise other medium:
CONTRACTOR AND INSTALLATION INFORMATION
18). Will construction be by a Contractor? () No (X )Yes
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If yes. Contractor will be: to be determined (initial Contractor contacted is Bryant and Fry)
Address:
Corporate Status:
Name and Phone Number of individual to contact in the event ofuestion :
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(Don Fry (512) 422-8662; Norman Fry (512) 422-8666)
19). Describe in detail the method and manner of installation on the Railroad Company's property: 2- 48" steel casings for 2- 36"
RCP storm drain pipes are proposed to be bored perpendicular to the rail bed at the appropriate depth beneath
the rail bed and adjacent fiber optic cables.
s.
GLACE ARROW INDICATING NORTH
RECTION RELATIVE TO CROSSING
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NO SCALE
FORM DR -0404-8
REV. 5-15-98
ENCASED NON-FLAMMABLE
PIPELINE CROSSING
NOTE: ALL AVAILABLE DIMENSIONS MUST BE
FILLED IN TO PROCESS THIS APPLICATION.
�i AREST R. R. TOfN/ �1
4 1 1 1
o
��ee�
e2 4"Tv (DESCRIBE FIXED OBJECT
`4���Z��� v� (SEE NOTE 6)
eN J ? IDISTANC ALONG TRAP( FROM SECTION LINE CROSSING/
11
FT.
RR' S RIR
(NOTE: THIS DIMENSION REOUIREO IN ALL CASES.
AT LOCATIONS NOT USING SECTIONS, DISTANCE
TO A LEGAL SURVEY LINE IS REOUIRED)
DESCRIBE FIXED OBJECT
(SEE NOTE 5)
FT.
_'_------�E-
F T. O FT.
15..
1
MIN. DIST
( See Note 2)
1
t•27i FT.
ALL NOR12ONTAI DISTANCES TO SE ME (CASING LENGTI( fNEN MEASURED ALONG PIPELINE.)
,ALL
TO ExTENp BEYOND INC E OF T� T RICHT ANGLES �f5 FITOMIE OF iRACR.
AND tIEY10 UNIT OF RAILROAD RICHT-OF-f47 INE ANGLES TIE GREATER OF 20 • 20 FT.. OR 30 FT.,
M (y NO SrFROM THE ENO NECESSARY TO PROVIDE PROPER LENGTH OUTSIDE OF TRACK.
SIGNAL OF Sr I7ROM I CCN O ANr RAILROAD BRIDGE, E OF aHr CULVERT, 0R FR01/ ANr SNITCHING AREA.
PRESENT DURING INSTALLATION IF RAILROAD SIGNALS ARE IN THE VICINITY OF
ALLONAOLE rIxED OBJECTS INCLUDE: 8� CHNALLS OF BRIDGES; E Or ROAD CROSSINGS >t _
OR CULVERTS.
CASING AND CARRIER PIPE(CrS Mt15T BE PLACED A MtNiMIAI OF FEIOIEAO VIADUCTS 1GIVE ROAD *14
S FEET OF THE EXISTING FIBER OPTIC CABLE 1UST BE HAND gam INCTfxISTiNG fiefR OPTIC emir_ ANY EIo(:AYA tT ON1rRf0U1RE0 WHIN
15 PIPELINE CROSSING WITHIN DEDICATED STREET ?
IF YES, NAME OF STREET
DISTRIBUTION LINE
CARRIER PIPE :
YES; 0;
OR TRANSMISSION LINE
COMMOO I TY TO 8E CONVEY D o •
OPERATING PRESSURE PSIAN
WALL THICKNESS -DIAMETER j,{ j,(I
CASING PIPE : -MATERIAL
WAIL THICKNESS //
NOTE :CASING MUST
;MATERIAL
OUTSIDE DIAMETER OF CARRIER PIPE CLEARANCE BETWEEN G E
CASING PIPE. WHEN FURNISHING DIMENSIONS, EGIVE OUTSIDETOF
CARRIER PIPE AND INSIDE OF CASING PIPE.
METHOD OFi INSTALLING CASING PIPE UNDER TRACK(S):
✓ORY BORE ANO JACK ( WET BORE NOT PERMITTED) ;
TUNNEL ;OTHER
gill CONSTRUCTION BE 8Y AN OUTSIDE CONTRACTOR?
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)ISTANCE FROM CENTER LINE OF TRACK TO NEAR FACE OF BORING AND'
TACKING PITS WHEN MEASURED AT RIGHT ANGLES TO TRACK ss�� 4 4
(PPL /CANT HAS CONTACTED 1-800-336-9193, (w�{MI'
1. P. CONMUIJION DEPARTMENT, ANO HAS DETERMINED FIBER
)DTIC CABLE DOES ; nc)FS NAT . FXIcT 131 V►e.t...T„ „r
STEEL CASING WALL
THICKNESS CHART
MINIMUM
THICKNESS
.2500"
.
2500-
.3125-
.3750'
.4375'
5000-
. 5625'
.6250'
1/4-
5/16'
3/8"
7/16'
l/2
9/16'
5/8"
DIAMETER OF
CASING PIPE
•12" OR LESS
OVER 12'-18'
OYER 18'-22"
OVER 2r-28'
OVER 28"-34"
OVER 34'-42'
OVER 42" -48 -
OVER 48" MUST BE
APPROVED 8Y R.R. CO.
NOTE THIS CHART IS ONLY
PIPES SMOOTH H MINIMUM YIELD
STRENGTH OF 35,000 PSI.
FORMULA TO FIGURE CAS I NC
LENGTH WITH ANGLE OF
CROSSING OTHER THAN 90•
EXHIBIT "A"
(FOS RAILROAD ItROAD YSE aNLn
8
MIN. DIST.
(NOTE 2)
UNION PACIFIC RAILROAD CO.
M.P_
ENCASED
(KESr Curs
RR FILE NO.
.S IVIS/jNI
E. S.
ICouttr.
I AM SCANT
CROSSING AT
DATE
WARNING
1N ALL OCCASIONS, U. F. COIU&WICATIONS
DEPARTMENT MUST BE CONTACTED IN ADVANCE
OF ANT ■OR K TO DETER..1.F cr.crc.rc ....
s Srac.