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Hamilton County Highway Department 1700 S. 10th Street Noblesville, IN. 46060 Ph: (317) 773-7770 Fax: (317) 776-9814 www.hamiltoncounty.in.gov NOTIFICATION OF EMERGENCY WORK IN RIGHT-OF-WAY HCHD Form 1018 Revised 02/16/11 Permit Instructions 1. Emergency cut: A situation where there is an immediate need to perform repair work on an existing utility service which has been interrupted or damaged and where the failure to perform such work would result in an immediate danger to life or property. 2. Notify a Hamilton County “Permit Inspector” as soon as possible. 3. Emergency during non-work hours, a faxed notification must be made to the Hamilton County Highway Department as soon as possible on Form 1018. 4. A regular permit and fee must be filed with the Hamilton County Highway Department within 72 hours of the time the work is begun in an emergency situation. 5. Any work completed as emergency work which does not meet the definition of emergency as set out in Hamilton County Code Title 8, Article 17, Chapter 3, Section 2 is a violation. Applicant’s Name Open Road Cut - Flowable Backfill Applicant’s Status (Must mark one) Contact Person Mailing Address City Project Location (Must be described in reference to centerlines of streets in feet.) Explain Emergency Situation I hereby certify that I have the authority to bind the above named applicant and the owner of the facilities being repaired under this permit to the terms, conditions and requirements of this emergency permit. I have received a copy of the code, read and fully understand all requirements of Hamilton County Code Title 8, Article 17, Chapter 3, Section 2 concerning the permit and construction process and require- ments. I also certify that I, the applicant and all persons performing the work authorized by this permit understand all requirements of the above referenced code and permit and will abide by all of their requirements and conditions. I further certify that I, the applicant and any persons performing work authorized by this permit will not make any changes in from the approved plan and permit without receiving written permission from the Hamilton County Highway Department. The applicant and owner agrees and understands that Hamilton County does not warrant the accuracy of the limits of the right-of-way shown on this permit and further that Hamilton County’s approval is limited to conveying it’s approval to install the approved facilities only within legal road right-of-ways. If the facilities as shown on this permit are not within legal road right-of-ways, it shall be the applicant’s duty to obtain the proper legal access to the property to install said facilities as shown on the plans. The applicant, owner and I agree to pay all attorney’s fees, court costs and other damages or costs incurred by Hamilton County in enforcing the terms of this permit, enforcing the County Code 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 Hamilton 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 Hamilton County or its successors. The applicant, owner 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. Signature Printed Name Applicant’s Internal Control # State Zip Code E-mail Phone # Date Title Individual Partnership Corporation Open Road Cut - Conventional Backfill Type of Emergency Work Placement / Removal of a Utility Pole Tap Pit NOTICE: A copy of this permit will be submitted to the Hamilton County Surveyor’s Office for review. Work in a regulated drain easement may require a permit. Applicant should contact the Surveyor’s Office prior to beginning construction if work is in a regulated drain easement. Verbal permission given by: IN