Atch_6_DOT_295_Permit_to_Occupy_Row.pdf

DOT-295

(12/25)

Sheet 1 of 2

SOUTH DAKOTA DEPARTMENT OF TRANSPORTATION

DOT-295: APPLICATION FOR PERMIT TO OCCUPY RIGHT-OF-WAY

Highway No. County Approximately Miles N S E W from (City or well-defined point) Section Township Range

Description of Occupancy:

Purpose of Occupancy:

Duration of Occupancy: PERMANENT TEMPORARY If temporary, estimated date of removal or completion:

I, the undersigned, request permission to occupy public right-of-way at the above location and as shown on the attached layout sheet. In consideration for this permission, I agree to abide by all conditions as herein stated.

1. To furnish all materials, labor, incidentals and pay all costs involved with this occupancy including restoration of any damage to the roadway and right-of-way to equal or better conditions than existed prior to the occupancy covered by this permit.

2. To provide protection to highway traffic during occupancy by the use of proper signs, barricades, flagpersons and lights as prescribed in the “Manual of Uniform Traffic Control Devices.”

3. To indemnify and hold the State of South Dakota, its Department of Transportation, its officers, agents and employees, harmless from and against any and all actions, suits, damages, liability or other proceedings of any kind or nature brought because of any injuries or damage received or sustained by any person or property on account of the use or occupancy of right-of-way designated in this application.

APPLICANT NAME (please print):

ADDRESS: PHONE:

REPRESENTING: EMAIL:

(Name of Individual, Company, Organization, etc.)

SIGNATURE: DATE:

*** To be completed by Department of Transportation***

Project: Station: Milepost: Maintenance Unit: Structure Number:

1. Prior to commencing occupancy and at completion of occupancy the applicant must notify:

At Phone: Email:

2. Special Conditions:

3. Failure to accomplish the occupancy in accordance with the provisions of this permit will automatically render this permit null and void and where applicable, constitute grounds for its removal and/or full restoration of the occupancy site all at the applicant’s expense.

This permit to occupy the right-of-way is granted subject to all conditions as herein stated.

Area Engineer Date Date Chief Bridge Engineer (for Bridge Installations only)

Region Engineer Date

DOT-295

(12/25)

Sheet 2 of 2

INSTRUCTIONS FOR DOT-295

APPLICANT:

1. Complete all items at the top of the form.

2. If the occupancy involves work within the right-of-way, prepare a separate sheet showing the work to be accomplished. The drawing should include:

a. Width of the highway from shoulder to shoulder

b. Width of the right-of-way

c. Details of the work to be performed by the occupancy

d. A North arrow

e. Installations on bridges must include details of the method(s) of attachment.

f. Any other pertinent information

3. Sign the form and submit it and any attachments to the applicable DOT Region Office for processing.

REGION OFFICE ADDRESSES & PHONE NUMBERS:

Aberdeen Region Office – Mailing Address: PO Box 1767 Aberdeen, SD 57402-1767 Physical Address: 2735 US 12 Aberdeen, SD 57401 Phone: 605-626-2244 (Aberdeen, Huron, and Watertown Area Offices)

Mitchell Region Office – Mailing Address: PO Box 1206 Mitchell, SD 57301-7206 Physical Address: 1300 S Ohlman Street Mitchell, SD 57301-7206 Phone: 605-995-8129 (Mitchell, Sioux Falls, and Yankton Area Offices)

Pierre Region Office – Mailing & Physical Address: 104 S Garfield Ave Bldg A Pierre, SD 57501 Phone = 605-773-3464 (Pierre, Mobridge, and Winner Area Offices)

Rapid City Region Office – Mailing Address: PO Box 1970 Rapid City, SD 57709-1970 Physical Address: 2300 Eglin Street Rapid City, SD 57703 Phone: 605-394-2244 (Rapid City, Belle Fourche, and Custer Area Offices)

DEPARTMENT OF TRANSPORTATION REGION OFFICE:

1. Complete the bottom portion of the form.

2. Installations involving bridges require review/approval of the Chief Bridge Engineer. If review by the Office of Bridge Design is necessary, allow two weeks for review.

3. If the request is denied, return the request to the applicant and state the reason for denial.

4. If the request is granted, make and send copies of the permit and attachments to:

a. Applicant

b. Area Engineer

c. Maintenance Supervisor

d. Chief Bridge Engineer (if applicable)

5. File the original copy in the Region Office and scan the signed documents into File Director under Document Type DOT-135.1.