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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 APPLICATION FOR SERVICE CONNECTION IN RIGHTS-OF-WAY HCHD Form 1013 Revised 02/16/11 Permit Instructions 1. This form may only be used for a tap pit and up to one bore or the installation of one pole to provide utility service to a home or business. No other work can be authorized by this permit. No cutting of road pavement or extension of distribution mains or lines is allowed by this permit. 2. Form must be completely filled out using a typewriter or printed in black ink. Any non-applicable blanks must be marked N/A. 3. Contact a Permit Inspector or consult the Hamilton County “Permit Manual for County Roads” for questions concerning this application. 4. A clear, detailed plan sheet must accompany this application. The drawing must show the R/W, edge of road, all construction details, driveways, field entrances, easements and other significant features within or immediately adjacent to the R/W. The plan must show distances to the nearest intersecting roads, dimensions of all construction and have a legend for all symbols used. Failure to include all of the above will result in the denial and return of your application. 5. The minimum permit bond amount for a service connection is $5000 per location. A higher amount may be required upon review of the application. The beneficiary on the permit bond shall be the “Board of Hamilton County Commissioners, Hamilton County Indiana”. 6. Permit fee shall be check or money order made payable to the “Hamilton County Treasurer”. Cash can not be accepted. When complete, mail or hand deliver this signed application, along with the permit fee, permit bond and detailed plan to the above address, Attention: “Permit Inspector”. Applicant’s Name NOTICE: Applicant’s Status (Must mark one) Contact Person Mailing Address City Project Owner’s Name (if different from applicant) Project Owner’s Address (if different from applicant) City Project Location (Must be described in reference to centerlines of streets in feet. Use HCHD form 1021 for additional locations in same project.) Project Purpose I hereby certify that I have the authority to bind the above named applicant and the owner of the facilities being installed under this permit to the terms, conditions and requirements of this 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 requirements. 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 attor- ney’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. I understand that this permit does not authorize the cutting of any road pavement for any purposes. Signature Printed Name Applicant’s Internal Control # State Zip Code E-mail Phone # Phone # Fax # State Zip Code Date Title Check or money order Individual Partnership Corporation Bond TOTAL PERMIT Bond Amount: Bond E-mail Placement of one utility pole for a service pole(s) @ $75 / each Tap pit ( ⇒ Includes a directly adjacent bore or push at no additional (No cutting of pavement is allowed. Pit size is limited to 100 square feet.) tap pit(s) @ $75 / each Bore or push under the roadway to provide a service connection………...……………... (No cutting of pavement is allowed.) bore(s) @ $75 / each 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. This permit is approved: Subject to the changes noted on the plans. Subject to the attached conditions. As submitted. Other Do not write in this Section - Highway Department Use Only $ 0 $ 0 $ 0 $ 0 IN IN