Fillable Printable Form 4176

Form 4176

Page 1 of 2 Record series 83-602

RIGHT-OF-WAY PERMIT

State Form 41769 (R8 / 5-17)

Approved by State Board of Accounts, 2017

Approved by Auditor of State, 2017

STATE OF INDIANA

INDIANA DEPARTMENT OF TRANSPORTATION

Type of permit:

Excavation Pole Line Railroad Miscellaneous Shared Use

Application number

District

Subdistrict

Telephone number

( )

Project location

Reference point number

Project description

Road number

County number

Project purpose

Expiration date (month, day, year)

Bond required?

YesNo

If Yes, penal sum

Bond number

Permit fee: (Make check or bank draft payable to “Indiana Department of Transportation.”)

Fee amounts per IC 8-23-2-6(13); fee schedule address: //www.in.gov/indot/2727.htm

Special provisions:

THE APPLICANT AGREES TO INDEMNIFY, DEFEND, EXCULPATE, AND HOLD HARMLESS THE STATE OF INDIANA, ITS OFFICIALS AND EMPLOYEES

FROM ANY

LIABILITY DUE TO LOSS, DAMAGE, INJURIES, OR OTHER CASUALTIES OFWHATSOEVER KIND, OR BYWHOMSOEVER CAUSED,

TO THE PERSON OR

PROPERTY OF ANYONE ON OR OFF THE RIGHT-OF-WAY ARISING OUT OF, OR RESULTING FROM THE ISSUANCE

OF THIS PERMITOR THE WORK

CONNECTED THEREWITH, OR FROM THE INSTALLATION, EXISTENCE, USE, MAINTENANCE, CONDITIONS,

REPAIRS, ALTERATION, OR REMOVAL OF ANY

EQUIPMENT OR MATERIAL, WHETHER DUE IN WHOLE OR IN PART TO THE NEGLIGENT ACTS

OR OMISSIONS (1) OF THE STATE, ITS OFFICIALS, AGENTS,

OR EMPLOYEES; OR (2) OF THE APPLICANT, HIS AGENTS, OR EMPLOYEES, OR

OTHER PERSONS ENGAGED IN THE PERFORMANCE OF THE WORK, OR (3)

THE JOINT NEGLIGENCE OF ANY OF THEM; INCLUDING ANY

CLAIMS ARISING OUT OF THE WORKMEN'S COMPENSATION ACT OR ANY OTHER LAW,

ORDINANCE, ORDER, OR DECREE. THE

APPLICANT ALSO AGREES TO PAY ALL REASONALBE EXPENSES AND ATTORNEY'S FEES INCURRED BY OR

IMPOSED ON THE STATE IN

CONNECTION HEREWITH IN THE EVENT THAT THE APPLICANT SHALL DEFAULT UNDER THE PROVISIONS OF THIS

PARAGRAPH.

Issue date (month, day, year)

Signature of permit applicant Printed name of permit applicant

Name of company organization

Telephone number

( )

Address (number and street, city, state, and ZIP code)

Inspector

Permit number

District Regulatory Supervisor

District Director

District addresses can be found at: //entapps.indot.in.gov/dotmaps/districtmaps/

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Page 2 of 2 Record series 83-602

State of Indiana

Department of Transportation

GENERAL PROVISIONS

Part of State Form 41769

1. All work described in the permit shall be subject to the inspection of the Department of Transportation and the permittee shall

adjust or stop operations upon direction of any police officer or Department of Transportation employee.

2. The permit may be rescinded at any time by the Department of Transportation at its discretion or for noncompliance with any

and/or all provisions of said permit.

3. The permittee shall notify the Department of Transportation Subdistrict five (5) working days preceding the beginning of any work

activity.

4. The permittee shall notify the Department of Transportation Subdistrict that the work is complete and this notice is to be provided

within seven (7) days from completion of all work on this permit.

5. The permittee shall have the permit complete with drawings and special provisions in their possession during work operations and

will show said permit on demand, to any police officer or authorized Department of Transportation employee.

6. The permittee shall pay the Department of Transportation for any inspection costs where it is necessary to assign a Department of

Transportation employee to inspect the work. The permittee shall immediately reimburse the State upon receipt of an itemized

statement.

7. The permit is valid through the stated expiration date. If work is not completed within the allotted time, the permit is automatically

cancelled unless an extension is requested prior to the expiration date and said request is approved by the Department of

Transportation. If a permit is cancelled, a new application must be submitted and approved before the proposed work can be

accomplished.

8. The permittee shall erect and maintain all necessary signs, barricades, detour signs, and warning devices required to safely direct

traffic over or around the part of the highway where permitted operations are to be done so long as the work does not interfere with

traffic, in accordance with Section “VI” of the Indiana Manual of Uniform Traffic Control Devices.

9. All construction and materials used within the highway right-of-way must conform to the current Department of Transportation

“Standard Specifications” with the permittee being considered in the same status as the contractor.

//www.state.in.us/dot/div/contracts/standards/index.html

10. The permitted operations shall not interfere with any existing structure on the Department of Transportation right-of-way without

specific permission in writing from the Department of Transportation. In the event that any buildings, railings, traffic control devices,

or other structures are damaged, said cost of the removal and/or damage shall be borne by the permittee.

11. This permit does not apply to any State roads or bridges that are closed for construction purposes, or to any county roads or city

streets.

12. Approval of the permit application shall be subject to the permittee obtaining all necessary authorizations from local authorities and

complying with all applicable laws. The issuance of the permit shall in no way imply Department of Transportation approval of, or

be intended to influence any action pending before a local board, commission, or agency.

13. The permitted operations shall be allowed on state highway right-of-way only between sunrise and sunset and shall not be

performed on Saturdays, Sundays, or during the period beginning at 12:00 Noon on the last weekday (Monday through Friday)

preceding and continuing until Sunrise on the day following: New Year’s Day, Memorial Day, Independence Day, Labor Day,

Thanksgiving, and Christmas.

14. In accordance with the notice requirements of Indiana Code 4-21.5, any objection to the conditions and provisions of an approved

permit must be submitted in writing to the Department of Transportation within fifteen (15) days from the issue date.

15. The permittee does hereby agree that (1) no person on the grounds of race, color, sex or national origin shall be excluded from

participation in, denied the benefits of, or be otherwise subjected to discrimination in the use of its facilities, (2) that in the event

facilities are constructed, maintained or otherwise operated on the said property described in this permit for a purpose for which a

Department of Transportation program or activity is extended or for another purpose involving the provision of similar services or

benefits, the permittee shall maintain and operate such facilities and services in compliance with all the other requirements

imposed pursuant to Title 49, Code of Federal Regulations, Department of Transportation, Subtitle A, Office of the Secretary, part

21 Nondiscrimination in Federally-assisted programs of the Department of Transportation – Effectuation of title VI of the civil Rights

Act of 1964, and as said Regulations may be amended