Utility_Map_Request_Form.pdf

CITY OF PALO ALTO

UTILITIES DEPARTMENT

UTILITY INFRASTRUCTURE INFORMATION

REQUEST REQUIREMENTS

INSTRUCTIONS

In order to obtain utility information concerning water, gas, wastewater, electric, or fiber infrastructure within the City of Palo Alto, a requestor must submit a Completed Utility Map Request Form.

A completed Map Request Form must include:

1. Completed and signed Map Request Form including the requestor’s contact info, what utility information is needed, the reason(s) for requesting the utility map, and requestor’s driver license information with signature (electronic signature is acceptable). If the information is requested on behalf of another agency/company, please also provide a contact name of the responsible person for that agency/company.

2. Signed Confidentiality Agreement (electronic signature is acceptable).

3. a. A vicinity map or image outlining the location and limits of the utility information requested. If the requested area covers more than 2 parcels, please include a map showing the exact alignment of the proposed pipe (example:

show the proposed telecom cable to be installed under the sidewalk on the north side of the street). The goal is to protect utility infrastructures by limiting the amount of sensitive information given out.

Submit Completed Utility Map Request Forms to:

UtilityMapRequest@cityofpaloalto.org City of Palo Alto – Utilities Engineering 1007 Elwell Court Palo Alto, CA 94303

(650) 566-4500

Rev. 8/18/2020

b. If the request is for a City CIP project, a map outlining the project area is not required.

mailto:UtilityMapRequest@cityofpaloalto.org

MAP REQUEST FORM

Email Address

Map Address Requested

Requestor's Name

Contact Number

Requestor's Company Name

Complete Address

Agency Representing

Contact from Agency

Contact Number

Address

Project Name

Requesting Utilities Information: (check all applicable utilities)

□ Water Gas Wastewater Electric Fiber

State Reason for Request:

This communication, including attachments, is for the exclusive use of addressee and may contain proprietary, confidential and/or privileged information. If you are not the intended recipient, any use, copying, disclosure, dissemination or distribution is strictly prohibited.

All map(s) generated are for reference only. The City of Palo Alto (CPA) does not warranty the accuracy of the map(s).

Requestor’s Driver's License Information

Full Name

State & Driver License #

Expiration Date

Signature

If requesting project drawings for bidding purposes, please provide:

Contractor License# ___________________________________

Date

CONFIDENTIALITY AGREEMENT

The undersigned DOCUMENT RECIPIENT has requested a copy of confidential drawings pertaining to utilities facilities owned by the City of Palo Alto (CITY) for the reasons described in DOCUMENT RECIPIENT’S Map Request Form submitted on:

(Effective Date).

CITY agrees to share such information (“Confidential Materials”) provided that DOCUMENT RECIPIENT agrees to keep the Confidential Materials confidential as follows:

1. DOCUMENT RECIPIENT acknowledges that the Confidential Materials are of a highly confidential nature, and agrees to hold such Confidential Materials in strict confidence and use them only for the proposed work described in the Map Request Form, and for no other purpose.

2. DOCUMENT RECIPIENT will allow the Confidential Materials to be held and viewed only by DOCUMENT RECIPIENT’s employees and agents who reasonably need to review the Confidential Materials for the purpose described in the Map Request Form (the “Reviewing Parties”).

6. DOCUMENT RECIPIENT confirms that DOCUMENT RECIPIENT is (check one):

□ A governmental agency or public utility

□ A consultant, contractor, subcontractor, supplier, or bidder doing business with or on behalf of the individual or organization disclosed on the Map Request Form

□ Other person or entity who needs the Confidential Materials for the following reasons (include company name as registered with the Secretary of State, person’s driver’s license, and/or contractor’s license):

3. DOCUMENT RECIPIENT will not copy, reproduce or alter the Confidential Materials in any form (including but not limited to paper copies and electronically formatted copies of all or any part of the Confidential Materials), or provide, distribute or share them in any form, or provide, distribute or share any information contained in them, to any other party (other than the Reviewing Parties), unless (i) DOCUMENT RECIPIENT has received written authorization to do so from City, or (ii) DOCUMENT RECIPIENT is required to do so under applicable law;

provided, however, DOCUMENT RECIPIENT shall give City no less than twenty (20) business days’ prior written notice to City of its intent to make any such law- related disclosure of the Confidential Materials or any information contained therein.

4. DOCUMENT RECIPIENT acknowledges that CITY is providing the Confidential Materials in their as is condition, without any representations or warranties as to how current the information is or the accuracy, completeness, fitness for any purpose, or merchantability of the Confidential Materials or the information in such materials.

5. Promptly at the conclusion of the proposed work for which the above- described confidential information was furnished, or at such time as the contract for the proposed work for which the Confidential Materials were furnished is awarded to someone other than the DOCUMENT RECIPIENT, DOCUMENT RECIPIENT shall destroy all Confidential Materials and all copies of same.

7. DOCUMENT RECIPIENT confirms that CITY can reach DOCUMENT RECIPIENT at:

8. This Confidentiality Agreement will be considered signed as of the Effective Date.

DOCUMENT RECIPIENT confirms and agrees to all of the above representations, conditions and stipulations.

RETURN AND PROVIDE ALL REQUIRED INFORMATION TO:

UtilityMapRequest@cityofpaloalto.org City of Palo Alto – Utilities Engineering 1007 Elwell Court Palo Alto, CA 94303

(650) 566-4500

Address:

Email:

Telephone:

SIGNATURE:

PRINT NAME:

TITLE:

mailto:UtilityMapRequest@cityofpaloalto.org