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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 TO WORK IN COUNTY ROADS RIGHTS-OF-WAY HCHD Form 1012 Revised 04/10/23 Permit Applicant’s Name 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 an purposes. Signature Printed Name Applicant’s Internal Control # State Zip Code # e n o h P lia m - E Phone # Fax # State Zip Code Date Title Check or money order Bond TOTAL PERMIT Bond Amount: Bond E-mail Do not write in this Section - Surveyor’s Office Use Only Drain(s) Affected: Permit Needed Non-enforcement Outlet Crossing Surveyor, Hamilton Date Instructions 1. Form must be completely filled out using a typewriter or printed in black ink. Any non-applicable blanks must be marked N/A. 2. Contact a Permit Inspector or consult the Hamilton County “Permit Manual for County Roads” for questions concerning this application. 3. 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. 4. The permit bond amount is based on the type and amount of work being authorized by this permit. Contact a Permit Inspector or the “Permit Manual for County Roads” for a specific amount. The beneficiary on the permit bond shall be the “Board of Hamilton County Commissioners, Hamilton County Indiana”. 5. 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”. Underground construction, grading, trenching or excavation parallel to the road….. (Fee is per 400 feet or portion thereof for each continuous location. No cutting of pavement is allowed.) feet @ $100 / 400 feet Bores or pushes under the bores @ $75 / each Placement/removal of poles/overhead (Fee is per 1000 feet or portion thereof for each continuous location.) feet @ $150 / 1000 feet Tap pit ( ⇒ Includes a directly adjacent bore or push at no additional (No cutting of pavement is allowed.) tap pits @ $75 / each Storage of dumpsters or construction materials within the weeks_______x sites @ $50 / week / site Do not write in this Section - Highway Department Use Only This permit is approved: Subject to the changes noted on the plans. Subject to the attached conditions. As submitted. This work does not affect the project. Does the work being approved by this permit lie within a HCHD planned project? If Yes above, the staff member in charge of the project must approve this permit. Yes No Other These plans accommodate the planned HCHD project. These plans make the best effort of avoiding future project conflicts based on the best information at this time. Applicant is hereby notified that relocation of facilities being installed under this permit will likely need to be relocated within 5 years. HCHD Staff Project Individual Partnership Corporation Government Agency Religious / Other Applicant’s Status (Must mark one) This project requires a variance. This project does not affect a regulated drain. This project affects a regulated drain(s) and an application must be made with the Hamilton County Drainage Board for construction within a drainage easement. $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 IN IN