Permit Application

Permit Type*

Construction Permit - Permit to Occupy
Construction Permit - Construction
Construction Permit - Activity Affecting Traffic
Annual Access Permit - Pursuant to Agreement
Annual Access Permit - Other
Access Permit

Permit Applicant Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

Enter Email Confirm Email

Project Description*

Check all that apply.

Other

Facility

(type, size, class of transmitting, design pressure or potential, etc.)

Nature of Installation

Longitudinal (parallel)
Transverse (crossing)
Buried
Aerial/Ground Mounted

Location

Station No.

City/Town

Milepost(s), Intersection

Additional Information

Permit Exhibits

Letter of Request*

Engineering Design Plans or Construction Drawings, Project Specifications

Insurance Certificate

Details of proposed work and location on an E-470 as-built(s)/aerial

Traffic Control Plan/Method of Handling Traffic

Schedule

Emergency Contact List

Acknowledgement*

Permittee’s request to use and/or occupy the E-470 right-of-way/multi-use easement (the “E-470 Property”) as described above is granted subject to the terms and conditions of this Permit, including all of the Exhibits attached hereto. IT IS UNDERSTOOD that the Permittee shall accomplish all work at no expense to E-470 Public Highway Authority (the “Authority”) and shall own and maintain any and all facilities permitted. Permittee acknowledges that nothing herein shall be interpreted to grant Permittee an easement or any other interest in real property comprising the E-470 Property. Permittee hereby agrees to indemnify, defend, protect and save the Authority, its directors, officers, agents and employees harmless from and against any loss of and/or damage to E-470 Property, third parties and/or Permittee’s facilities and all loss and/or damage on account of injury to or death of any person whomsoever, arising at any time, caused by or growing out of the use and/or occupation of E-470 Property by Permittee’s facilities or any plan thereof, including but not limited to installation, adjustment, relocation, maintenance, operation and/or removal of facilities, unless such loss and/or damage arises from the sole negligence or willful conduct of the Authority or its employees or agents. Failure by the Permittee to comply with any of the included terms and conditions may subject this Permit to suspension or cancellation, at the sole discretion of the Authority. No work shall be permitted that infringes on the mainline lanes and no traffic control devices shall be placed within two (2) feet from the outermost solid white line during the hours of 6 a.m. to 9 a.m. and 3 p.m. to 6 p. p. In accepting this Permit, the undersigned, representing the Permittee, represents that he or she has the authority to sign for and bind the Permittee and that he or she has read, understands and accepts all the included conditions. This Permit is not valid until fully endorsed by all parties, with the date of issue affixed by an authorized representative of the Authority. This Permit expires 120 days after issuance. A fully executed copy of this Permit must be on file at the E-470 Public Authority administrative office.

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