TALBOT COUNTY ROADS DEPARTMENT
REQUEST TO PERFORM WORK IN TALBOT COUNTY ROAD R-O-W
□ SUBCONTRACTOR □ RESIDENTIAL □ PROJECT
DATE PERMIT NO.
1. APPLICANT NAME
ADDRESS
PHONE
EMAIL
2. COMPANY/INDIVIDUAL PERFORMING WORK
ADDRESS
PHONE
EMAIL
3. WORK TO BE DONE
4. DATE WORK WILL BEGIN
5. LOCATION OF WORK TO BE DONE
□ Driveway □ Utility Work □ Other □ Within County ROW □ Outside County ROW
6. MISS UTILITY LOCATE #
DATE
7. MHIC AND/OR BUSINESS LICENSE OFSUBCONTRACTOR (if applicable) #
EXP DATE
8. INSURANCE COMPANY NAME: PHONE NO.
9. DIRECT SUPERVISOR PHONE CELL OFFICE
10. PERMIT # AND/OR P.O. # FROM GENERAL CONTRACTORS
TO SUBCONTRACTOR
11. LIST ANY ATTACHED DOCUMENTS WITH THIS REQUEST
12. SUBMIT TRAFFIC PLAN IF NECESSARY □ YES □ NO
13. SUBMIT EMERGENCY PLAN IF REQUIRED □ YES □ NO
ALL WORK SHALL BE PERFORMED IN ACCORDANCE WITH APPLICABLE LAWS, REGULATIONS, SPECIFICATIONS AND
REQUIREMENTS AND TO THE SATISFACTION OF THE TALBOT COUNTY ROADS DEPARTMENT. PERMITTEE IS
RESPONSIBLE FOR ANY DAMAGE TO COUNTY ROADS AND THE ROAD IS TO BE RETURNED TO ITS ORIGINAL CONDITION.
PERMITTEE IS RESPONSIBLE FOR OBTAINING ALL NECESSARY PERMITS AND/OR APPROVALS, INCLUDING, BUT NOT
LIMITED TO, TALBOT COUNTY GRADING PERMIT, SOIL CONSERVATION EROSION AND SEDIMENT CONTROL PERMITS,
MISS UTILITY OF DELMARVA, ETC. PERMITTEE SHALL NOTIFY THE TALBOT COUNTY ROADS DEPARTMENT WHEN WORK
IS TO BEGIN, WHEN WORK IS TO BE INSPECTED, AND WHEN THE WORK IS COMPLETE. PERMITTEE SHALL PROVIDE THE
TALBOT COUNTY ROADS DEPARTMENT WITH A WORKING PHONE NUMBER OF A CONTACT PERSONWHO SHALL
REMAIN AVAILABLE FOR COMMUNICATION UNTIL THE WORK HAS BEEN INSPECTED, APPROVED AND ACCEPTED. ALL
WORK MUST BE DONE DURING REGULAR WORKING HOURS UNLESS OTHERWISE APPROVED BY THE TALBOT COUNTY
ROADS SUPERINTENDENT. ALL WORK MUST BE INSPECTED, AND APPLICANT/CONTRACTOR WILL BE RESPONSIBLE FOR
ALL REPAIRS CAUSED BY DEFECTIVE WORK WITHIN60 TO 180 DAYS, WHETHER BEFORE OR AFTER ACCEPTANCE BY THE
COUNTY. TRAFFIC MUST BE MAINTAINTED AT ALL TIMES AS PER MARYLAND STATE HIGHWAY ADMINISTRATION
STANDARDS.
INSPECTION FEE (CONTRACTOR): $50/INSPECTION OR ZONE PER PERMIT
□ CASH □CHECK NO. □WAIVED
