HomeMy WebLinkAbout1986-013 Utility Permit - RobertsDISTRIBUTION:
APPLICATION NO.
DATE \.~.! i
PERMIT NO.
White - Office Yellow - App2icant
~ JACKSON COUNTY
DEPARTMENT OF PUBLIC WORKS
APPLICATION FOR FACILITY PERMIT
Green- Inspector/Supervisor
PERMIT TYPE AND FEE COLLECTED:
Driveway/Road Approach
Road Encroachment
Road Improvement:
Major
Minor
Special
Utility
I, ~'" .:.S'~ .3 ~ hereby make application for a facility
(Applicant's Name - Please Print)
permit upon the right-of-way of ~ ~..' Milepost(s)
(Road Name - County Road Number)
in strict conformity to the exhibits attached hereto, subject to all terms, conditions, agreements,
stipulations, and provisions contained in the application and permit, and the rules and regulations
regarding roads and rights-of-way, as set forth by Jackson County Ordinance No 'and the
Public Works Direct~.r's Permit Policy, and any other applicable regulations, law or ordinance.
DESCRIPTION OF FACILITY:
Signature
(Phone where you can be reached)
Mailing Address
City State Zip
(Applicant Do Not Write Below This Line)
FACILITY PERMIT
SPECIAL PROVISIONS: The terms and specifications which apply to this permit
are as shown on the attachment herewith and the permit conditions listed on
the reverse side of this application. Noncompliance with these terms,
specifications and conditions will result in cancellation of this permit.
ATTACHMENTS FOR:
Driveway/Road Approach Special
Road Encroachment Utility
Road Improvement Other
ADDITIONAL REQUIREMENTS:
This permit shall be void unless the work herein contemplated shall have been completed before
?~,~ ~:: , ': i , 19
INSPECTED:
Date ~ Approved : 7 [] Approved
Issue Date
By [] Denied [] Denied
~" Director of Public Works
PERMIT CONDITIONS:
A. This permit covers public right-of-way and/or County property only.
It is the responsibility of the permit holder to re-establish any survey monument moved,
destroyed, etc. while working within County right-of-way. Re-establishment of survey
monuments must be done by an approved registered surveyor and all costs will be borne by
the permit holder.
Notification of Jackson County, Department of Public Works, Permit Section, is required
24 hours before beginning work under this permit - 826-3122 or 776-7268. Prior approval
for modifications to permit specifications is required.
Permits may be terminated or suspended when the permit holder is found to have obtained a
permit through misrepresentation of the facts or when, in the Judgment of the Director of
Public Works, terms of the permit are being violated or public safety is threatened. Access
permits shall remain in effect until a change in land use occurs. The permit holder shall
be responsible for the cost of design, installation or construction of additional roadway
improvements and traffic control devices at any time in the future when the traffic
generated by the use for which the access permit is authorized necessitate such installation
in the interest of the public safety.
HOLD HARMLESS CLAUSE - The permit holder agrees that their performance under this permit is
at their own sole risk and that they shall indemnify Jackson County, its agents and employees,
and hold them harmless from any and all liability for dmmsges, costs, losses and expenses
resulting from, arising out of, or in any way connected with this permit, or from the permit
holder's failure to perform fully hereunder, and the permit holder further agrees to defend
Jackson County, its agents, and employees, against all suits, actions or proceedings brought
by any third party against them for which the permit holder would be liable hereunder.
F. The permit holder guarantees all restoration work for a period of two years from the date of
completing the installation.
Any sight posts, sign posts, or mailboxes that are removed will be replaced immediately in like
condition in the same location and the area around them will be restored to a like or better
condition.