2. Contact Details
4. First Name*
5. Last Name*
7. Email Address*
8. Telephone*
10. Address*
12. City*
13. State*
14. Zip*
16. Preferred Method of Response*
    -- Select One --EmailTelephoneNo Response Required
20. 1. Date(s) of Closure*
    1. Date(s) of Closure Start Date

    —

    1. Date(s) of Closure End Date

    Request must be submitted at least 7 days in advance of closure.

21. Additional Date
    Additional Date Start Date

    —

    Additional Date End Date
23. 2. Alternative date(s) if weather affects work*
    2. Alternative date(s) if weather affects work Start Date

    —

    2. Alternative date(s) if weather affects work End Date
24. Additional Date
    Additional Date Start Date

    —

    Additional Date End Date
26. 3. Times*
    3. Times Start Time

    —

    3. Times End Time
27. Additional Time
    Additional Time Start Time

    —

    Additional Time End Time

29. If dates have to be changed outside of the requested dates, a new application must be made.

33. Officers Required and Payment

    The City holds to the right to determine the total number of officers needed for any road closures based on public safety concerns.
    

    If determined or requested that officer(s) are needed, the rate is $50 an hour with a minimum of four (4) hours. If a project runs over the estimated time, the applicant must pay for the additional time at the rate of $50 an hour.

    Pay is expected on the day of work, unless otherwise negotiated prior to the date of the closure. 

35. 4. Are you requesting police officers to provide traffic control?*

    1. yes
    2. no
37. a. How many officers are you requesting?*
39. b. Form of Payment?

    1. Check
    2. Cash
40. c. Is the officer required to become a 1099 contracted employee for this project?

    1. Yes
    2. No
44. 5. Location
46. a. Primary road affected? *
47. b. Cross streets where the closure(s) will occur? *
49. c. If no cross streets are listed, provide GPS coordinates of where the road will have the closure(s) (start to end).*
53. 7. Is this a partial or full road closure? *

    1. Partial
    2. Full
54. 8. Is a detour required for a project? *

    1. Yes
    2. No
58. 10. Are signs and/ or barricades required for the road closure? *

    1. Yes
    2. No
60. Who is providing signs and/or barricades for the closure?*

    1. The applicant or contractor is providing signs and/or barricades.
    2. The City is being requested to provide signs and/or barricades.
    3. N/A
64. 11. If closures affect U.S. Hwy 278 (E. College, N. Avondale Rd., Covington Hwy.) in any way, has GDOT approved the request? *

    1. No
    2. Pending
    3. Approved
    4. Does not affect
66. Cancelation of project date(s) must be made 48 hours prior to the requested date or vendor will have to pay the officer(s) the minimum of $50 an hour for 4 hours ($200) to all that have been scheduled.
Leave This Blank:


68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit

* indicates a required field