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Residential Driveway and Culvert Permit Request This report must be complete by the applicant and the Roads & Bridges Representative. Once permit is complete return it to the Building Inspector’s office with a $35.00 permit fee. Roads and Bridges (706) 342-0821 Applicant Information Date: Name: Address: City: Zip Code: Day time Phone Number: Construction Site Information Driveway Type: Agricultural Commercial Industrial Residential Location: Nearest Intersection: By signing this request, I agree to construct or have driveway constructed as described below. Signature Date OFFICIAL USE ONLY Roads & Bridges Driveway Material: Gravel Concrete Asphalt Pavers Pervious Material Culvert Needed: Yes No Culvert Size: Culvert Right of way: feet Culvert Setback: from edge of road Permit Approved By Signature: Print Name: Date: MORGAN COUNTY PLANNING AND DEVELOPMENT Post Office Box 1357 150 East Washington Street, Suite 200 Madison, Georgia 30650 (706) 342-4373 Office (706) 343-6455 Fax ---PAGE BREAK--- MORGAN COUNTY COMMISSSIONERS 150 East Washington Street, Suite 100 Madison, GA 30650 P.O. Box 168 Madison, GA 30650 INDEMNIFICATION AGREEMENT THIS AGREEMENT, made this of between hereinafter referred to as “Indemnitor”, and the (Property Owner) Morgan County Board of Commissioners a political subdivision of the State of Georgia, hereinafter referred to as “Morgan County”. For good and valuable consideration, receipt of which is acknowledged, it is hereby agreed: Section 1. Liability, Loss or Damage. Indemnitor, hereby agrees to indemnify Morgan County and hold Morgan County harmless from any and all claims, demands, attorneys’ fees and cost of defense of judgment against it, arising from Indemnitor’s use of the County’s road right of way for the installation of a Culvert and driveway on (Road or Street Name) Section 2. Damages, Indemnitor hereby agree to repair or reimburse Morgan County for necessary costs to repair damages reasonable caused by such person’s construction of access to Morgan County public roadway. Section 3. Duration. Indemnity under this agreement shall commence on the date of execution hereof and shall con- tinue in full force for a period of one years from said commencement date. Section 4. Notice. So long as Indemnitor keeps Morgan County informed of Indemnitor’s Current address, Morgan County shall notify Indemnitor of all claims made against Morgan County that are subject to this Indemnification Agreement. IN WITNESS WHEREOF, the parties have executed this agreement at Madison, Georgia, the day and year first above written. Morgan County, Georgia (SEAL) Indemnitor (Property Owner) Subscribed and sworn before me on this Current Address Notary Public Phone Number My Commission Expires: