Fillable CITY OF MURRAY ENCROACHMENT PERMIT DEPARTMENT OF ENGINEERING (City of Murray)

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CITY OF MURRAY ENCROACHMENT PERMIT DEPARTMENT OF ENGINEERING (City of Murray)

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CITY OF MURRAY
DEPARTMENT OF ENGINEERING
ENCROACHMENT PERMIT
RELEASED DATE_______________________ PERMIT NO. ___________
APPLICANT IDENTIFICATION
NAME:_________________________________________
CONTACT PERSON:_______________________________
ADDRESS:______________________________________
CITY:_________________________________________
STATE:______________________ZIP CODE__________
PHONE:( )__________________________________
EMAIL: _______________________________________
PROJECT IDENTIFICATION
STREET:_________________________NO._________
LOCATION ON STREET: ____NORTH ____SOUTH
____EAST ____WEST ____X-ING
PROJECT STATUS: ____MAINTENANCE
____CONSTRUCTION
TYPE OF ENCROACHMENT:
____COMMERCIAL ENTRANCE - BUSINESS____________
PRIVATE ENTRANCE: ____SINGLE FAMILY ____FARM
____UTILITY ____OVERHEAD ____UNDERGROUND
____GRADE: ____FILL ____LANDSCAPE ON R/W
____AIRSPACE: ____AGREEMENT ____LEASE
____OTHER (SPECIFY)_______________________________
____________________________________________________
____________________________________________________
ATTACHMENTS:
PLEASE LIST EACH ITEM TO BE ATTACHED
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
________________________________________
TYPE OF INDEMNITY:
____BOND ____CASH
____SELF-INSURED AMOUNT ENCUMBERED $__________
____OTHER
NAME AND ADDRESS OF LOCAL
INSURANCE AGENCY OR SELF-INSURED
REPRESENTATIVE
__________________________________
__________________________________
__
__________________________________
_
BRIEF DESCRIPTION OF WORK TO BE DONE:
(If private entrance, show sketch with pipe
location. Separate attached drawings required for encroachments other than private entrances.)
IMPORTANT: (PLEASE READ)
WHEN THE WORK IS COMPLETED IN ACCORDANCE WITH THE TERMS OF THIS ENCROACHMENT PERMIT
YOUR INDEMNITY WILL BE RELEASED. HOWEVER, THE PERMIT IS EFFECTIVE UNTIL REVOKED BY
THE CITY OF MURRAY AND THE TERMS ON THE PERMIT AND ACCOMPANYING PERMIT DOCUMENTS AND
DRAWINGS REMAIN IN EFFECT AS LONG AS THE ENCROACHMENT EXISTS. FUTURE MAINTENANCE OF
THE ENCROACHMENT IS THE RESPONSIBILITY OF THE PERMITTEE. IT IS IMPORTANT THAT YOU
UNDERSTAND THE REQUIREMENTS OF THIS ENCROACHMENT PERMIT APPLICATION AND ACCOMPANYING
DOCUMENTS. IF YOU HAVE NOT DONE SO, IT IS SUGGESTED THAT YOU REVIEW THESE DOCUMENTS
AND PLACE THE PERMIT PACKAGE IN A SAFE PLACE FOR FUTURE REFERENCE.
A COPY OF THIS PERMIT AND ALL DOCUMENTS SHALL BE GIVEN TO YOUR CONTRACTOR AND SHALL
BE READILY AVAILABLE AT THE WORK SITE FOR THE ENCROACHMENT PERMIT INSPECTOR TO REVIEW
AT ALL TIMES. FAILURE TO MEET THIS REQUIREMENT MAY RESULT IN CANCELLATION OF THIS
PERMIT.
IN THE EVENT THIS APPLICATION IS APPROVED, THIS DOCUMENT SHALL CONSTITUTE A PERMIT
FOR THE APPLICANT TO USE THE RIGHT-OF-WAY, BUT ONLY IN THE MANNER AUTHORIZED BY THIS
DOCUMENT AND REGULATIONS OF THE DEPARTMENT AND THE DRAWINGS, PLANS, ATTACHMENTS AND
OTHER PERTINENT DATA ATTACHED HERETO AND MADE A PART HEREOF.
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EMAIL
THE PERMITTEE AGREES TO THE FOLLOWING TERMS AND CONDITIONS:
1. The permittee shall comply with and is bound by the requirements of the City of Murray on the date of the issuance of this
permit.
2. Any permit granted hereunder shall be with the full understanding that it shall not interfere with any similar rights or
permits heretofore granted to any other party except as otherwise provided by law.
3. A plan prepared by ____________________ and dated _____________ is attached hereto and made a part hereof, which describes the
facilities to be constructed by the permittee for which facilities this permit is granted. The permittee agrees as a
condition to the issuance of the permit to construct and maintain such facilities in accordance with said plan, and the
permittee shall no use the facilities authorized herein in any manner contrary to that prescribed by the permit and plan.
Normal usage and routine maintenance only are authorized under this permit.
4. Permittee shall at all times from date when work is first commenced and until such time as all facilities are removed from the
right-of-way premise, defend, protect and save harmless the City of Murray from all liability, claims, and demands arising out
of work undertaken by the permittee pursuant to this permit, due to any negligent act or omission by the permittee, its
servants, agents, employees or contractors. This provision shall not inure to the benefit of any third party or operate to
enlarge any liability of the City beyond that existing at common law if this right to indemnity did not exist.
5. Upon a violation of any of the provisions of this permit, the City may revoke the permit by giving notice to the permittee in
writing to remove from the right-of-way any facilities placed thereon within a reasonable time as set forth in the notice, and
in the event said facilities are not so removed, and the right-of-way restored the City may cause same to be removed, and the
costs thereof shall be charged to the permittee.
6. The permittee, his successors and assigns shall use the encroachment premises in compliance with all Federal requirements
imposed pursuant to the provision of the Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000-1) and regulations of the
U.S. Department of Transportation as set forth in Title 49 C.F.R., Part 21, and as said regulations may be amended.
7. Permittee agrees that in the event it should become necessary, as may be reasonably determined by the City for the facilities
covered by this permit to be removed or relocated in connections with the reconstruction, relocation or improvement of the
abutting highway, the City may revoke this permit and require removal or relocation by the permittee at his own expense
according and pursuant to the procedures provided in Paragraph 8 above except in those cases where the City is required by law
to pay any or all the same.
8. The permittee understand and agrees that this permit is personal to the permittee and shall no inure to his successors and
assigns without the written approval of the City and that he is bound by the provisions of this permit as long as the
encroachment exists unless a written release has been obtained from the City.
9. This permit does not alleviate any requirements of any other government agency.
THE UNDERSIGNED APPLICANT (BEING DULY AUTHORIZED REPRESENTATIVE/OWNER) DOES AGREE TO ALL TERMS AND CONDITIONS SET FORTH
HEREIN.
JANUARY 1st _ JULY 1st __ ,20 ,20__ ______________________________
Completion Date Date Signature
RECOMMENDED FOR APPROVAL
TITLE__________________ SIGNATURE____________________________ DATE_______________________
PRIVATE ENTRANCE: TO BE COMPLETED BY PERSONNEL INSTALLING FACILITY.
INSTALLED BY: ___________________________ ____________________________ __________________20 ___
TITLE SIGNATURE DATE
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CITY OF MURRAY ENCROACHMENT PERMIT DEPARTMENT OF ENGINEERING (City of Murray)

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Completed 14 July 2020

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