Fillable 2017 Annual Contractor

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2017 Annual Contractor

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U.S.A. forms for Talbot County Government

BROWSE TALBOT COUNTY GOVERNMENT (MD) FORMS

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PERMIT NUMBER:
TALBOT COUNTY ROADS DEPARTMENT
APPLICATION FOR CONSTRUCTION ACTIVITY
(ANNUAL PERMIT)
Approval of this permit gives permission to the holder to perform routine maintenance in Talbot County
Road rights-of-way ONLY, at the discretion of the Talbot County Roads Superintendent. Any non-routine
work or special projects require a Project/Subcontractor Permit
1. APPLICANT NAME:
a. Address:
b. Telephone:
c. Business Phone: Cell:
d. Email:
2. MHIC or Business License: Expiration Date:
3. Job Supervisor:
4. Telephone: Cell:
5. INSURANCE COMPANY:
a. Policy Number:
b. Certificate of Insurance:
c. Telephone:
6.
PLEASE ATTACH A LIST OF CURRENT SUBCONTRACTORS (Call our office 410-770-8150 as subcontractors are
added throughout the year).
7. List any attached documents with this request:
I solemnly declare or affirm under the penalties of perjury that I am authorized to make and execute this application on behalf of the Applicant,
Contractor, and Subcontractor, as the case may be, and that the contents of the foregoing Application are true and correct to the best of my
knowledge, information, and belief. The Applicant, Contractor, and Subcontractor, jointly and severally (collectively the “Permittee”) agree to abide
by all terms, conditions, and requirements of this Permit and shall be jointly and severally responsible for performance of the work in accordance
with all such requirements.
Printed Name
Signature DATE
ADDITIONAL TERMS AND CONDITIONS ON REVERSE
1. Permittee shall provide at least 24-hour advance notice to Talbot County Roads Department ("TCRD") before any work may begin.
2. Permittee shall perform all work only during regular working hours unless expressly approved by the Talbot County Roads Superintendent.
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3. All work shall be performed in a good and workmanlike manner in accordance with applicable laws, regulations, codes, standards, and other
requirements.
4. Permittee is responsible for maintaining roadway, traffic, and pedestrian safety at all times. Permittee shall indemnify and hold Talbot County,
its officers, agents, and employees harmless from and against any and all liability, claims, suits, actions, causes of action, demands, and
damages, including personal injuries and death, and all other losses, including, without limitation, litigation costs and reasonable attorneys
fees arising from, related to, or connected with performance or failure to perform any work under or related to this Permit.
5. All work shall be inspected. No work shall proceed until TCRD has inspected and approved each phase that is required to be inspected.
Permittee is responsible to notify TCRD and obtain all required inspections. TCRD may require Permittee to uncover, remove, and redo work
that has been performed without a required inspection.
6. Permittee shall promptly notify TCRD upon completion of the work and request a final inspection. Permittee shall maintain all work in
satisfactory condition until it has been inspected and accepted by TCRD. Permittee shall provide the an “as-built” drawing of the completed
work accompanying the request for final inspection.
7. Permittee is responsible for any damage to County property resulting from or arising out of performance of the work or any activity related to
issuance of the Permit. Permittee shall, at its sole cost, promptly repair or replace all such damages to the reasonable satisfaction of TCRD.
8. Permittee shall complete all work to the satisfaction of TCRD; TCRD may require the Permittee to repair, replace, or reconstruct all or any part
of any unsatisfactory or improper work.
9. Permittee is responsible for obtaining all other local, State, or Federal permits or approvals required for the work, including without limitation
grading permits, soil, sediment, and erosion control permits, and Miss Utility of Delmarva locates. Permittee's failure to obtain any such
permit, approval, or locate shall not relieve the Permittee of its responsibility to perform all work in accordance with all applicable
requirements.
10. Permittee shall immediately notify TCRD if any information contained in this application changes or becomes inaccurate or incomplete, or of
any changed or unanticipated conditions or circumstances that affect the time for completion or Permittee's ability to perform the work in
accordance with all applicable requirements. Permittee shall immediately notify TCRD of any damages to County property, any injuries, losses,
or other events that may result in a claim against the County.
11. TRAFFIC MUST BE MAINTAINED AT ALL TIMES IN ACCORDANCE WITH MARYLAND STATE HIGHWAY ADMINISTRATION STANDARDS.
ANNUAL FEE: $150.00
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2017 Annual Contractor

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Completed 16 February 2020

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