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2. Instructions

   By submitting this document, Applicant certifies that all conditions and special provisions attached to this permit have been completed in compliance with permit requirements and any and all specifications and special provisions attached to the original permit. With this submittal, County Personnel will conduct a final inspection.

   Prior to demobilizing from the project location(s), the Applicant shall notify the Highway Department after construction is complete so that a final inspection may be performed by County Highway personnel. Special conditions required by the County may be applied to this permit and shall be complied with by the Applicant pending Final Approval. If any deficiencies are noted during the final inspection, the Applicant will responsible to correct deficiencies within 30 days of notification.

4. Utility Company
5. Date
   Date
7. Applicant Name
9. Address
11. Business Phone
12. Cell Phone
14. Email
16. Site Foreman Name
17. Cell Phone
19. Email
20. Permit No.
22. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
24. Electronic Signature
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field