ROW Permit Application Form

ROW PERMIT APPLICATION AND AGREEMENT

Application Information

Application No.:    Date Filed:

Whereas

WHEREAS, Applicant Name: (the "Applicant") seeks authorization to perform work within the public right-of-way under the jurisdiction of Issuing Authority: ; and

WHEREAS, the Issuing Authority requires that the proposed work be performed in accordance with all applicable laws, standards, and permit conditions and that the Applicant provide required fees, insurance, bonds and restoration obligations as set forth in this Permit and Agreement.

Applicant Contact Information

Individual    Corporation    LLC    Other:

Project Location & Description

Scope of Work

Describe the proposed work to be conducted in the right-of-way, including methods, equipment, and extent of disturbance. Attach plans as required.

Schedule and Traffic Control

Proposed Start Date:    Proposed End Date:

Restoration, Bonds & Insurance

Restoration Description: The Applicant shall restore disturbed right-of-way to the condition required by the Issuing Authority. See restoration standards attached.

Insurance: Before issuance of the permit, Applicant shall provide insurance certificates evidencing commercial general liability, automobile liability and worker's compensation as required by the Issuing Authority.

Payment Terms

Permit Fee Amount:    Deposit Required:

Late Fee: . Applicant agrees that failure to timely pay required fees, deposits or restoration costs may result in suspension or revocation of permit and assessment of collection costs.

Term and Termination

Permit Term Start Date:    Permit Term End Date:

Notice Period for Termination: Either party may terminate this Permit and Agreement for material breach upon written notice delivered days prior to termination, except that the Issuing Authority may immediately suspend or revoke the permit where imminent threat to public safety or property exists.

Confidentiality

Applicant acknowledges that plans, financial information and other submittals may be retained by the Issuing Authority. Except as required by law or as necessary for enforcement of this Permit and Agreement, confidential submittals will be treated as non-public to the extent permitted by law. Applicant shall clearly mark materials claimed confidential and shall indemnify the Issuing Authority for any disclosure of marked confidential materials by Applicant.

Indemnification

Applicant shall indemnify, defend and hold harmless the Issuing Authority and its officers, employees, and agents from and against all claims, liabilities, losses, damages, costs and expenses (including reasonable attorneys' fees) arising out of or related to Applicant's performance of work in the right-of-way, except to the extent caused by the negligent acts or omissions of the Issuing Authority.

Permits, Compliance and Conditions

Applicant certifies that all work will comply with applicable codes, ordinances, standards and conditions set forth by the Issuing Authority, including but not limited to traffic control, erosion control, safety protocols, and restoration standards. Permit approval may be conditioned upon prior inspections, deposits, bonds, and insurance.

Governing Law and Entire Agreement

Governing Law: This Permit and Agreement shall be governed by and construed in accordance with the laws of the jurisdiction of the Issuing Authority. Governing Jurisdiction:

Entire Agreement: This document, together with any referenced attachments, plans and conditions of approval, constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes any prior written or oral agreements.

Attachments and Additional Information

Attachments included (check all that apply):

Plans/Drawings    Traffic Control Plan    Insurance Certificates    Bond Documents    Other:

Applicant Certification

By submitting this application, the Applicant certifies under penalty of law that the information provided is true and correct, that the work will be performed in accordance with this Permit and Agreement and applicable laws, and that Applicant will provide required bonds and insurance prior to commencement of work.

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