Affidavit of Compliance for Right-of-Way Permits

City Ordinance 395-2 requires that before a permit is issued to perform any work on or use municipal property or a municipal-controlled public right of way, all contractors and subcontractors performing work under the permit must file an affidavit providing the following:

  1. Proof of authorization or registration to transact business in the state by the Department of Financial Institutions in compliance with chs. 178, 179, 180, 181, or 183;
  2. A representation and warranty that the entity is not, at the time of submission of the permit application, debarred by any federal or state agency;
  3. A representation and warranty that the entity is familiar with, and agrees to follow, Wisconsin’s one call requirements, Wis. Stat. § 182.0175, for the project, maintains a safety program, has not been in OSHA’s severe violator enforcement program in the previous two years, and whatever additional information the department may require to ensure that the entity will safely perform the work; and
  4. A copy of the written plan meeting the requirements of Wis. Stat. § 103.503(3) and a representation and warranty that the entity is in compliance with the testing requirements set forth in Wis. Stat. § 103.503(3)(a)2.

A contractor or subcontractor failing to provide the required affidavit, or failing to meet the affidavit criteria, shall not be allowed to excavate within, or place any facilities within, over or on, any municipal property or municipal-controlled right-of-way. 

The Affidavit of Compliance can be downloaded, signed and notarzied, and uploaded with your permit application.  Or, the Affidavit can be completed and notarized at City Hall, located at 5211 Schluter Road.