ADPT-Permit.pdf

ADOT ENCROACHMENT PERMIT APPLICATION, REVISED December 2009 Page 1 of 2

ARIZONA DEPARTMENT OF TRANSPORTATION

INTERMODAL TRANSPORTATION DIVISION

Highway Encroachment Permit Application (Application for Permission to Use State Highway Right-of-Way)

FOR ADOT USE

PERMIT NUMBER:____________________________ ROUTE: __________________________ MILEPOST: ____________________

ADOT PROJECT NUMBER: ______________________________ ADOT ENGINEERING STATION: ________________________ Name of Encroachment Owner:

Address of Owner:

City:

State: Zip:

Phone:

E-mail address:

Name of Applicant (If other than the Encroachment Owner):

Mailing Address:

City:

State: Zip:

Phone:

Legal Relationship to Owner:

City (in or near): _______________________________ Side of Highway: N S E W (check one)

Highway Route No. _________ Approximately __________ Feet N S E W (check one) of Milepost No ______

Project No. or Parcel No.: ______________________________ Project Duration : ________________________________

Description of the proposed work or activity in the right-of-way: ___________________________________________

The Encroachment Owner will be the Permittee. By signing this application, the Encroachment Owner/Permitee and the Applicant hereby acknowledges that the information given and statements made in this application are true and correct to the best of his/her knowledge. The Encroachment Owner agrees as the Permittee to accept the following General Obligations and Responsibilities as described on page 2 of the application. By accepting an approved encroachment permit, the Permittee agrees to the requirements described in the permit, to be responsible for all permit requirements, and to comply with ADOT's requirements as set out in the permit. An approved permit consists of this application, final supporting documentation approved by ADOT, and any requirements set by ADOT. If the Permittee disagrees with the requirements, the Permittee shall return the permit immediately to the District Office.

NO WORK SHALL TAKE PLACE INSIDE THE RIGHT OF WAY WITHOUT AN APPROVED PERMIT ON SITE.

Encroachment Owner (Print Name and Sign) Applicant (Print Name and Sign)

Date_______________________________________________ Date__________________________________________________

ADOT ENCROACHMENT PERMIT APPLICATION, REVISED December 2009 Page 2 of 2

GENERAL OBLIGATIONS AND RESPONSIBLITIES

THE PERMITTEE AND/OR APPLICANT AGREES TO THE FOLLOWING:

1. Assume all legal liability and financial responsibility for the encroachment activity for the duration of the encroachment, including indemnify, defend, and hold ADOT and the State of Arizona and any of it's agents, directors, officers, employees harmless from and against any and all claims, actions, losses, liabilities, costs, damages, or expenses, including court costs, reasonable attorney's fees, and costs of claim processing and investigation, arising out of bodily injury or death of any person, or tangible or intangible property damage, caused, or alleged to be caused, in whole or in part, by the negligent or willful acts, or omissions of the Permittee, any of its directors, officers, agents, employees, or volunteers, or its contractor or subcontractors. This indemnity includes any claim or amount arising out of or recovered under the Workers' Compensation Law or arising out of the contractor's failure to conform to any federal, state or local law, statute, ordinance, rule, regulation or court decree. The Permittee is not responsible for claims arising solely from ADOT's negligent or willful acts or omissions. The Permittee and/or contractors and subcontracts may be required to procure insurance with specified limits naming the State of Arizona and ADOT as additional insureds.

2. Comply with Environmental Laws. A. Environmental Laws refers collectively to any and all federal, state, or local statute, law, ordinance, code, rule, regulation, permit, order, or decree regulating, relating to, or imposing liability or standards of conduct on a person discharging, releasing or threatening to discharge or release or causing the discharge or release of any hazardous or solid waste or any hazardous substance, pollutant, contaminant, water, wastewater or storm water, and specifically includes, but is not limited to: The Solid Waste Disposal Act, as amended by the Resource Conservation and Recovery Act; the Comprehensive Environmental Response, Compensation and Liability Act, as amended; the Toxic Substances Control Act; the Clean Water Act (CWA); the Clean Air Act; the Occupational Safety and Health Act; the Arizona Water Quality Act Revolving Fund Act, the Arizona Hazardous Waste Management Act, any applicable National Pollutant Discharge Elimination System (NPDES) or Arizona Pollution Discharge Elimination System (AZPDES) permit, any applicable CWA Section 404 permit, or any local pretreatment or environmental nuisance ordinance.

B. The Permittee specifically agrees that in the course of performing any activity for which this Permit is necessary:

i. To comply with any and all Environmental Laws;

ii. To ensure that no activity under this Permit shall cause ADOT to be in violation of any Environmental Laws;

iii. That if the Permittee fails or refuses to comply with any Environmental Laws, or causes ADOT to be in violation of any

Environmental Laws, ADOT may at its sole and unreviewable discretion, (1) revoke this Permit; (2) require the Permittee to undertake corrective or remedial action to address any release or threatened release or discharge of the hazardous substance, pollutant or contaminant, water, wastewater or storm water; and (3) expressly consents to entry of injunctive relief to enforce any listed remedies.

iv. To indemnify ADOT for any losses, damages, expenses, penalties, liabilities or claims of any nature whatsoever suffered by or asserted against ADOT as a direct or indirect result of the disposal, escape, seepage, leakage, spillage, discharge, emission, or release of any hazardous waste, solid waste, hazardous substance, pollutant or contaminant, water, wastewater or storm water and losses, damages, expenses, penalties, liabilities and claims asserted or arising under the Environmental Laws, or for ADOT's costs in undertaking corrective action pursuant to an order of or settlement with a duly authorized regulatory agency or injured third party or for any penalties associated with Permittee's activities;

3. Be responsible for any repair or maintenance work to the encroachment for the duration of the encroachment;

4. Comply with ADOT's traffic control standards;

5. Obtain written approval from the abutting property owner (and/or underlying fee owner where ADOT owns its right of way by easement) if the encroachment encroaches on abutting property owned by someone other than the permittee (and/or on underlying fee land owned by someone other than the permittee where ADOT owns its right of way by easement).

6. Upon notice from ADOT, repair any aspect or condition of the encroachment that causes danger or hazard to the traveling public;

7. Remove the encroachment and restore the right-of-way to its original or better condition if ADOT cancels the encroachment permit, and terminates all rights under the permit;

8. Reimburse ADOT for costs incurred or deposit with ADOT money necessary to cover all costs incurred for activities related to the encroachment, such as inspections, restoring the right-of-way to its original or better condition, removing the encroachment, or repair encroachment to originally permitted condition;

9. Notify a new owner to apply for an encroachment permit, as required by Arizona Administrative Rule R17-3-502(D);

10. Apply for a new encroachment permit if the use of the permitted encroachment changes;

11. Keep a copy of the encroachment permit at the work site or site of encroachment activity;

12. Construct the encroachment according to plans that ADOT approves as part of the final permit;

13. Obtain required permits from other government agencies or political subdivisions;

14. Remove any defective materials, or materials that fail to pass ADOT's final inspection, and replace with materials ADOT specifies.

15. If the permit application is denied, applicant has a right to a hearing as prescribed in Arizona Administrative Rule, R17-3-509.

This application is approved as a permit and a permit is issued to the Permittee. Construction is authorized only for the period indicated below.

Authorized ADOT Name and Signature Authorized ADOT Name and Signature

Issue Date ________________________ Permit work to be completed by:__________________________________

PERMIT TO USE STATE HIGHWAY RIGHT-OF-WAY

FOR ADOT USE

Encroachment_Permit_application.pdf

ADOT

Highway Encroachment Permit Application D:20060831160610- 07'00' D:20070613161714- 07'00' ADOT ENCROACHMENT PERMIT APPLICATION, REVISED December 2009

ARIZONA DEPARTMENT OF TRANSPORTATION

INTERMODAL TRANSPORTATION DIVISION

Highway Encroachment Permit Application

(Application for Permission to Use State Highway Right-of-Way)

FOR ADOT USE

PERMIT NUMBER:____________________________ ROUTE: __________________________ MILEPOST: ____________________ ADOT PROJECT NUMBER: ______________________________ ADOT ENGINEERING STATION: ________________________ Name of Encroachment Owner:

Address of Owner:

City:

State:

Zip:

Phone:

E-mail address:

Name of Applicant (If other than the Encroachment Owner):

Mailing Address:

City:

State:

Zip:

Phone:

Legal Relationship to Owner:

City (in or near): _______________________________ Side of Highway: N S E W (check one) Highway Route No. _________ Approximately __________ Feet N S E W (check one) of Milepost No ______ Project No. or Parcel No.: ______________________________ Project Duration : ________________________________ Description of the proposed work or activity in the right-of-way: ___________________________________________ The Encroachment Owner will be the Permittee. By signing this application, the Encroachment Owner/Permitee and the Applicant hereby acknowledges that the information given and statements made in this application are true and correct to the best of his/her knowledge. The Encroachment Owner agrees as the Permittee to accept the following General Obligations and Responsibilities as described on page 2 of the application. By accepting an approved encroachment permit, the Permittee agrees to the requirements described in the permit, to be responsible for all permit requirements, and to comply with ADOT's requirements as set out in the permit. An approved permit consists of this application, final supporting documentation approved by ADOT, and any requirements set by ADOT. If the Permittee disagrees with the requirements, the Permittee shall return the permit immediately to the District Office.

NO WORK SHALL TAKE PLACE INSIDE THE RIGHT OF WAY WITHOUT AN APPROVED PERMIT ON SITE.___________________________________________________ ______________________________________________________Encroachment Owner (Print Name and Sign) Applicant

(Print Name and Sign) Date_______________________________________________ Date__________________________________________________ ADOT ENCROACHMENT PERMIT APPLICATION, REVISED December 2009

GENERAL OBLIGATIONS AND RESPONSIBLITIES

THE PERMITTEE AND/OR APPLICANT AGREES TO THE FOLLOWING:

1.

Assume all legal liability and financial responsibility for the encroachment activity for the duration of the encroachment, including indemnify, defend, and hold ADOT and the State of Arizona and any of it's agents, directors, officers, employees harmless from and against any and all claims, actions, losses, liabilities, costs, damages, or expenses, including court costs, reasonable attorney's fees, and costs of claim processing and investigation, arising out of bodily injury or death of any person, or tangible or intangible property damage, caused, or alleged to be caused, in whole or in part, by the negligent or willful acts, or omissions of the Permittee, any of its directors, officers, agents, employees, or volunteers, or its contractor or subcontractors. This indemnity includes any claim or amount arising out of or recovered under the Workers' Compensation Law or arising out of the contractor's failure to conform to any federal, state or local law, statute, ordinance, rule, regulation or court decree. The Permittee is not responsible for claims arising solely from ADOT's negligent or willful acts or omissions. The Permittee and/or contractors and subcontracts may be required to procure insurance with specified limits naming the State of Arizona and ADOT as additional insureds.

2.

Comply with Environmental Laws. A. Environmental Laws refers collectively to any and all federal, state, or local statute, law, ordinance, code, rule, regulation, permit, order, or decree regulating, relating to, or imposing liability or standards of conduct on a person discharging, releasing or threatening to discharge or release or causing the discharge or release of any hazardous or solid waste or any hazardous substance, pollutant, contaminant, water, wastewater or storm water, and specifically includes, but is not limited to: The Solid Waste Disposal Act, as amended by the Resource Conservation and Recovery Act; the Comprehensive Environmental Response, Compensation and Liability Act, as amended; the Toxic Substances Control Act; the Clean Water Act (CWA); the Clean Air Act; the Occupational Safety and Health Act; the Arizona Water Quality Act Revolving Fund Act, the Arizona Hazardous Waste Management Act, any applicable National Pollutant Discharge Elimination System (NPDES) or Arizona Pollution Discharge Elimination System (AZPDES) permit, any applicable CWA Section 404 permit, or any local pretreatment or environmental nuisance ordinance.

B. The Permittee specifically agrees that in the course of performing any activity for which this Permit is necessary:

i.

To comply with any and all Environmental Laws;

ii.

To ensure that no activity under this Permit shall cause ADOT to be in violation of any Environmental Laws;

iii. That if the Permittee fails or refuses to comply with any Environmental Laws, or causes ADOT to be in violation of any Environmental Laws, ADOT may at its sole and unreviewable discretion, (1) revoke this Permit; (2) require the Permittee to undertake corrective or remedial action to address any release or threatened release or discharge of the hazardous substance, pollutant or contaminant, water, wastewater or storm water; and (3) expressly consents to entry of injunctive relief to enforce any listed remedies.

iv. To indemnify ADOT for any losses, damages, expenses, penalties, liabilities or claims of any nature whatsoever suffered by or asserted against ADOT as a direct or indirect result of the disposal, escape, seepage, leakage, spillage, discharge, emission, or release of any hazardous waste, solid waste, hazardous substance, pollutant or contaminant, water, wastewater or storm water and losses, damages, expenses, penalties, liabilities and claims asserted or arising under the Environmental Laws, or for ADOT's costs in undertaking corrective action pursuant to an order of or settlement with a duly authorized regulatory agency or injured third party or for any penalties associated with Permittee's activities;

3.

Be responsible for any repair or maintenance work to the encroachment for the duration of the encroachment;

4.

Comply with ADOT's traffic control standards;

5.

Obtain written approval from the abutting property owner (and/or underlying fee owner where ADOT owns its right of way by easement) if the encroachment encroaches on abutting property owned by someone other than the permittee (and/or on underlying fee land owned by someone other than the permittee where ADOT owns its right of way by easement).

6.

Upon notice from ADOT, repair any aspect or condition of the encroachment that causes danger or hazard to the traveling public;

7.

Remove the encroachment and restore the right-of-way to its original or better condition if ADOT cancels the encroachment permit, and terminates all rights under the permit;

8.

Reimburse ADOT for costs incurred or deposit with ADOT money necessary to cover all costs incurred for activities related to the encroachment, such as inspections, restoring the right-of-way to its original or better condition, removing the encroachment, or repair encroachment to originally permitted condition;

9.

Notify a new owner to apply for an encroachment permit, as required by Arizona Administrative Rule R17-3-502(D);

10. Apply for a new encroachment permit if the use of the permitted encroachment changes;

11. Keep a copy of the encroachment permit at the work site or site of encroachment activity;

12. Construct the encroachment according to plans that ADOT approves as part of the final permit;

13. Obtain required permits from other government agencies or political subdivisions;

14. Remove any defective materials, or materials that fail to pass ADOT's final inspection, and replace with materials ADOT specifies. 15. If the permit application is denied, applicant has a right to a hearing as prescribed in Arizona Administrative Rule, R17-3-509.

This application is approved as a permit and a permit is issued to the Permittee. Construction is authorized only for the period indicated below.

Authorized ADOT Name and Signature Authorized ADOT Name and Signature Issue Date ________________________ Permit work to be completed by:__________________________________

PERMIT TO USE STATE HIGHWAY RIGHT-OF-WAY

FOR ADOT USE