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~.rG~"T OF WAY USE PERMIT Engineering Dept., Montrose ~" ,inty
<br />' IZ1 S. Townsend Ave., Montrose, CO 81401
<br />(970)252-7000
<br />PERMTTTEE Department Use Only t~
<br />Name ~ -~ 1 -~ ~ y (= G t .Date Issued , ~~"0 ~~ l
<br />PemvtNo. P o~c~ S ~
<br />Address ,' ? S Road Name / ~
<br />'~ i T` '~ _. Road Set7ment ID /- 30c~
<br />Inspection Fee ~ /DO . U Zl
<br />- 1-Z~2 (L„ ---~ Weed Control Fee ~ ~5. U ~ i D) /~T~ D
<br />ACTIVITY DESCRIPTION (Furnished by Permittee)
<br />PURPOSE ^ Installation ^ Adjustment/Relocation ^ Removal ^ Maintenance of existing facility ~ Other
<br />FACILITY (Type, size, class of transmittant, design pressure or potential, etc.) -~-'~ 4 >~- ale S (-C o ° _
<br />WILL WORK BE SUBCONTRACTED ^ Yes ^ No NAME OF SUBCONTRACTOR ,L1-~-~~
<br />NATURE OF INSTALLATION ^ Longitudinal (Pazallel) ^ Transverse (Crossing) ^ Fixed Object
<br />Misc. Surface Disturbance ^ Open Cut ^ Boring ^ AeriaUGround Mounted ^ Misc. Non-Surface Disturbance
<br />LOCATION Road Name y ~ I~~ Address City/Town
<br />Section/Township/Rattge - Subdivision
<br />Name of Person being Serviced
<br />START DATE OGT. 2 qT~n [T-I / FIMSH DATE ~ l`~~'11 7 '~~ ? DAR"
<br />ADDITIONAL REMARKS
<br />For underground location information, contact: Telephone
<br />Surface area to be disturbed ~ cal DRl 1 H r C (Length) Z O 1 f Widthl ZO'
<br />PLANS: Attach plans or work sketch ("Exhibit A") showing location, character, dimension, and detail of the work to be done. 1 set minimum
<br />YYV ~~`~utred. Compliance with the plans or sketch, as approved by the County; shall be a condition of this permit.
<br />INSURANCE: A Certificate of Insurance sh g compliance with the Standard Provisions shall be attached to and made part of this
<br />e 't.Insurance. Certificate provided for Permittee es ^ No ; For Subcontractor ^ Yes ^ No
<br />t :. , \\
<br />IN + Permittee is prohibited from commencing any work within road ROW prior to issuance of a fully endorsed and validated permit.
<br />Permit, plan exhibit, insurance certificate(s), and traffic control plans must be available on site during work.
<br />L Your request to use and/or occupy county road system right of way as described above is granted subject to the feints and conditions of this
<br />permit, including the Standard and Special Provisions, as shown do the FRONT and BACK haeoC IT I5 UNDERSTOOD that the Petmittee will accomplish the work
<br />at no cxprnse to the county and will own and maintain the facilities permitted.
<br />rNT ~ Permittee hereby assumes, releases and agrees to indemnify, defend, and protect and save the County of Montrose hatrttltss from and against any
<br />loss of and/or damage to the property of the County oC Montrose, third parties or the Pcmtittce's facilities, and all loss and/or damage on account of injury to or death of
<br />any person whomsoever, arising at the time, caused by or growing out of the occupation of Montrose County Road rights of way to Permittee's facilities or any part
<br />thereof, including, but not limited to, installation, adjustmcni, relocation, maintenance or operation, or removal of existing facilities, unless such loss and/or damage arise
<br />fro a sol n igence or willful conduct of the County of Montrose or its employees or agents.
<br />1NT Failure by Permittee to comply with any of the included temu or conditions may subject this permit to suspension or cancellation, at the
<br />discretion of the County. Working in the right-of--way without a fully endorsed and valid permit on site at work location shall constitute a violation of CRS 43-5-301,
<br />Obs ing hi way -penalty. .
<br />INTL THIS PERMIT IS NOT VALID UNTIL FULLY ENDORSED AND DATED BY AUTHORIZED REPRESENTATNES OF BOTH THE
<br />PERM E AND COUNTY. A fully executed copy of this permit shall be filed with the County Engineering Off ce. In accepting this permit the undersigned
<br />representing the Permittee verifies that he or she has the authority to sign for and bind the Permittec and that he or she has read, understand and fully accepts all of the
<br />included conditions.
<br />PERIVIITTEE/AUT O
<br />BINDING AGENT: TITLE:.~~~zit~2i~ J DATE: /D~..~.~-07
<br />As the authorized representative of the Utility to a installed under this Permit, I acknowledge that the installation work is not being performed by any
<br />contract with the Utility I represent nor under my supervision and assume no responsibility for the workmanship for any problems that might result
<br />during the 2 yr warranty period as specified under the "Operations & Maintenance" section of this Permit. 1 do acknowledge that the Utility I
<br />represent is the Owner of the facility to be installed under this Permit and as such takes full responsibility for any problems or damages arising from
<br />this installation after the 2 yr warranty period referred to above, or in the event that the installation contractor cannot be located.
<br />UTILITY:
<br />REPRESENTATIVE:
<br />
<br />SPECIAL PROVISIONS (Completed by County)
<br />All work shall only be in accordance with the approved plans, Standard Provisions, and Special Provisions as set forth in this permit.
<br />The County Inspector is Tim Holman Telephone 252-7001 or 209-7204
<br />^ Traffic Control Plan ^ Approved Traffic Control Plan ^ Sign work azea
<br />Work time restrictions:_ Davlit?ht hours and Weekdays only
<br />Required location aids (Tape, Trace Wlre, Row Markers)
<br />SURETY TYPE Issuer
<br />Identification # n .. P7rIlPCtPll RPIPOCP Th•P
<br />RNIIT ISSUANCE
<br />By % / 2~
<br />unty or Date
<br />WARRANTY AND SURETY RELEASE
<br />sy
<br />County Inspector Date
<br />DATE:
<br />v
<br />of
<br />By
<br />County Engineer/Road Supervisor Date of Release
<br />Revised Aug, 2007
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