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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 CLOSE COUNTY ROAD HCHD Form 1019 Revised 02/17/11 Permit 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 section of road to be closed, the points of closure, the nearest intersecting road at each end of the closure and the detour route to be posted. 4. The minimum permit bond amount for a service connection is $1000 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”. 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”. Applicant’s Name A permit to close a county road is not required when an approved Form 1011, Form 1016 or Form 1017 has been issued. Applicant’s Status (Must mark one) Contact Person Mailing Address City Promoter’s Name (if different from applicant) Promoter’s Address (if different from applicant) City Details of Traffic Control (Law Enforcement, Barricades, Signs, Detour Route, etc.) Name of Event / Reason for Road Closure I hereby certify that I have the authority to bind the above named applicant and the promoters of this event for the road closure 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 require- ments. I also certify that I, the applicant and all persons performing the road closure 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 promoter and any persons closing the road authorized by this permit will not make any changes in the closure 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 close the road only within legal road right-of-ways. If the road closure 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, promoter 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 promoter under this permit and I understand that Hamilton County may revoke this permit at any time, at no cost to Hamilton County. The appli- cant, the promoter 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. The applicant, promoter and I agree to hold harmless the County for any damage, accidents or other liabilities incurred as a result of this road closure and to pay all judgments and legal costs incurred by the County as a result of this road closure. Signature Printed Name Applicant’s Internal Control # State Zip Code Phone # Fax # State Zip Code Date Title Check or money order Individual Partnership Corporation Bond Permit Fee: day(s) @ $50 / day Bond Amount: Bond Time: AM PM Requested Road to be Closed: Day of Week: Mo Tu We Th Fr Sat Sun E-mail From To Date: Date: Day of Week: Mo Tu We Th Fr Sat Sun Time: AM PM Do not write in this Section - Highway Department Use Only County Approved by the Hamilton County Board of Commissioners Auditor This permit is approved: Subject to the changes noted on the plans. Subject to the attached conditions. As submitted. E-mail Phone # $ 0 IN IN