Fillable Land Use Permit Application Form printable pdf download

LAND USE PERMIT

LUP-A

Land Use Permit Application

March 10, 2016

APPLICATION is hereby made for permit as shown on the accompanying plan or sketch and as described below. Said activity(s) wi ll be done under and in accordance with the rules and regulations of the

Commonwealth Transportation Board of Virginia, in so far as said rules are applicable thereto and any agreement between the p arties herein before referred to. Where applicable agreements may be

attached and made a part of the permit assembly including any cost responsibilities covering work under permit. Applicant agrees to maintain work in a manner as approved upon its completion. Applicant

also hereby agrees and is bound and held responsible to the owner for any and all damages to any other installations already in place as a result of work covered by resul ting permit. Applicants to whom

permits are issued shall at all times indemnify and save harmless the Commonwealth Transportation Board members of the Board, the Commonwealth and all Commonwealth employees, agents, and

offices, from responsibility, damage, or liability arising from the exercise of the privileges granted in such permit to the extent allowed by law. In consideration of the issuance of a permit the applicant

agrees to waive for itself, successors in interest or assigns any entitlements it may otherwise have or have hereafter under the Uniform Relocation and Assistant Act of 1972 as amended in event the

Department or its successor, chooses to exercise its acknowledged right to demand or cause the removal of any or all fixtures, personality of wh atever kind or description that may hereafter be located,

should this application be approved.

Type or print clearly

Applicant Driver’s license or Tax ID No. _________________________

Contact Name ____________________________________________

Owner Name ________________________________________________

E-mail Address __________________________________________

Address ____________________________________________________

Telephone Number ( ______ ) _______ - ____________

City ________________________State ______Zip Code_____________

Emergency Telephone Number ( ______ ) _______ - ________

Fax Number ( ______ ) _______ - __________

Agent Driver’s license or Tax ID No. ____________________________

Contact Name ___________________________________________

Agent Name ________________________________________________

E-mail Address __________________________________________

Address ____________________________________________________

Telephone Number ( ______ ) _______ - ____________

City ________________________State ______Zip Code_____________

Emergency Telephone Number ( ______ ) _______ - _______

Fax Number ( _____ ) _______-__________

Permit Term Requested ________ Fees Enclosed $____________ Check Number ____________ Coupon Number(s) _______________________

Money Order _________________ Other __________ Estimated cost of work to be performed on VDOT Right of Way $_____________________

Surety Information:

Surety Posted by: Owner [

] Agent [

]

Surety Refund to: Owner [

] Agent [

]

Surety Waived [

]

Amount of Surety $ ____________________ Obligation Amount $_________________ Check # ________________

Surety Company Name ____________________________________________ Bond #__________________________

Applicant shall provide proof of registration as an operator with the appropriate notification center in accordance as defined in §2.2-1151.1 of the Code of Virginia & must provide a notarized

affidavit, stating that the utility owner has notified the commercial and residential developer, owner of commercial or multifamily real estate, or local government entities with a property

interest in any parcel of land located adjacent to the property over which the land use is being requested, that application for the permit has been made.

Request permission to perform the following activity(s): ________________________________________________________________________

_________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________as per attached plans.

Location: [

] County [

] Town [

] City of __________________________ Route No. ________ Street Name ______________________________

Latitude _________________ Longitude__________________ Tax Map Number _______________________ Applicant Job No.__________________

Between Route No. _________ Street Name _________________________ and Route No._________ Street Name ___________________________

[

] IF APPLICABLE, I AGREE TO PAY THE FULL SALARY AND EXPENSES OF A STATE ASSIGNED INSPECTOR IN CONJUNCTION WITH

ACTIVITIES AUTHORIZED UNDER THE AUSPICES OF A VDOT LAND USE PERMIT

Signature of Applicant: _____________________________________________ Title __________________________

Date ___________________

Signature of Agent: ________________________________________________ Title __________________________

Date ___________________

All applicable items on this form must be completed to avoid delay in processing the issuance of a VDOT Land Use Permit.

Prepayment required with remittance payable to Virginia Department of Transportation.

VDOT USE ONLY

Receipt is hereby acknowledged for: CHECK No.: ___________________________

MONEY ORDER No.: ______________________________

In the Amount of $ _________________________ for PERMIT FEE $ _________________________ CASH SURETY $ _________________________

Authorized VDOT Signature: ____________________________________________________ Date: ____________________________________

Land Use Permit Application Form

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