APPLICATION TO WORK IN COUNTY ROAD RIGHT OF WAY
PERMIT NO. _______________
Warrick County Commissioners P.O. Box 749, Boonville, IN 47601
Phone No. 812-897-6120 Fax No. 812-897-6189
Underground construction, grading, trenching or excavation parallel to the road _____ ft.@ $70/400 ft. = _______
Bores or pushes under the roadway _____ bores@$50/ea. = _______
Placement/removal of poles/overhead lines _____ ft.@$100/1000 ft. = _______
Tap pit (includes a directly adjacent bore or push at no additional fee) _____ tap pits@$50/ea. = _______
Open Cut across a County Road Right-of-Way _____ ft.@$5/ft. or
Minimum of $100 = _______
Check or Money Order No. _______________ TOTAL PERMIT FEE = _______
Bond Company: _______________________ Bond Amount: $_______ Bond # __________
Applicants Name: ______________________________________________________________________________________________
Mailing Address: ______________________________________________ P.O. Box No. ______________________________
City: ________________________________ State __________________ Zip Code: ____________Phone No. _____________
Fax No. ____________________________________ Contact Person: ________________________________________________
Project Owners Name (if different from applicant) ____________________________________________ Phone No. ______________
Project Owners Address (if different from applicant) __________________________________________________________________
City: ________________________________________ State ________________ Zip Code: ___________ Phone No. _____________
Fax No. ____________________________
Project Location (Must be described in reference to centerlines of streets in feet) __________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Project Purpose _____________________________________________________________________________________________
______________________________________________________________________________________________________________
I hereby certify that I have the authority to bind the above named applicant and the owner of the facilities being installed under this permit to the terms, conditions and requirements of this permit. I certify that I, the applicant and all persons performing the work authorized by this permit understand all requirements of the Ordinance adopted by the Board of Commissioners and will abide by all of the requirements and conditions. l further certify that I, the applicant and any persons performing work authorized by this permit will not make any changes in work from the approved plan and permit without receiving written permission from the Warrick County Board of Commissioners. The applicant and I agree to pay all attorney's fees, court costs and other damages or costs incurred by Warrick County in enforcing the Ordinance or which are a result of litigation incurred by the County as a result of this permit. The applicant, the owner of the facilities being installed under this permit and I understand that in the event Warrick County determines that any of the facilities installed under this permit need to be repaired, relocated or removed from the right-of-way, that the owner or any subsequent owner of the facilities agrees to maintain, relocate or remove these facilities in a timely manner at no cost to Warrick County or its successors. The applicant and I agree that the commencement of work covered by this permit will serve as our acceptance of all terms, conditions and requirements of the approved permit.
____________________________________________________ Date: _________________________________________
Signature
_____________________________________________________ ________________________________________________
Printed Name Title
DO NOT WRITE IN THIS SECTION-FOR DEPARTMENT USE ONLY:
County Highway Engineer ___________________________________________________ Date: __________________
This Permit is Approved:
As submitted.
Subject to the attached conditions.
Subject to the changes noted on the plans.
COMMENTS: ________________________________________
COMMISSIONERS MEETING DATE OF APPROVAL: __________________________________________
_____________________________________________________________
Commissioner Signature
_____________________________________________________________
Commissioner Signature
_____________________________________________________________
Commissioner Signature
INSTRUCTIONS:
1. Form must be completely filled out using a typewriter or printed using black ink. Any non-applicable blanks must be marked N/A.
2. Contact Warrick County Engineer for questions concerning this application.
3. A clear, detailed plan sheet must accompany this application. The drawing must show the R/W, edge of road, all construction details, driveways, field entrances, easements and other significant features within or immediately adjacent to the R/W. The plan must show distances to the nearest intersecting roads, dimensions of all construction and have a legend for all symbols used. Failure to include all of the above will result in the denial and return of your application.
4, The permit bond amount is based on the type and amount of work being authorized by this permit. Contact the Warrick County Highway Engineer or Board of County Commissioners for a specific amount. The beneficiary on the permit bond shall be the "Board of Warrick County Commissioners, Warrick County, Indiana".
5. Permit fee shall be check or money order made payable to the "Warrick County Treasurer." Cash can not be accepted. When complete, mail or hand deliver this signed application, along with the permit fee, permit bond and detailed plan to the above address, "Attention: County Highway Engineer"