Scdot Form 800 01 – Fill Out and Use This PDF

Ｉｌｏｈ＃Ｑｒ＝＃

Ｓｕｒｍｈｆｗ＃Ｑｒ＝＃

ＷＫＨ＃ＶＷＤＷＨ＃ＲＩ＃ＶＲＸＷＫ＃ＦＤＵＲＯＬＱＤ＃

ＦＲＸＱＷ＼＃ＲＩ＃

Ｕｒｄｇ＃Ｑｒ＝＃ Ｕｒｄｇ＃Ｌｑｉｒ＝＃

ＤＪＵＨＨＰＨＱＷ＃

ＺＫＨＵＨＤＶ／＃

has moved, or caused to be moved, certain buildings, fences, signs, or other obstructions from the right-of-way or in connection with the right- of-way which was acquired or granted for the construction of the above file,

which has/have been moved and find the condition of the said

to be equal or better than the condition before moving, I, as owner, do hereby release and bind my heirs, executors, administrators, and assigns to release the contractor, , who moved the said , and the DEPARTMENT OF TRANSPORTATION from any further work or responsibility in

connection with the above mentioned work.

ＬＱ＃ＺＬＷＱＨＶＶ＃ＺＫＨＵＨＲＩ／ I have hereunto set my hand and seal this

_____ day of _________________ , in the year of our Lord, __________________

Owner’s Signature

_______________________________________ (L.S.)

Landowner’s Signature

_______________________________________ (L.S.)

In the presence of:

_________________________________

Contractor’s Representative

_________________________________

Witness

File Reference

This agreement is intended to cover Item Nos. This is to certify that I have personally inspected the above moving item or items and find that the moving has been done and all work incident thereto has been satisfactorily completed. I have also contacted the property owner or his/her authorized agent who states that they have signed this agreement without any reservations, they are completely satisfied with the work and condition of the item moved and expect

no further work, payment, or other consideration from the contractor or Department.

Resident Engineer:

Ｖｌｊｑｄｗｘｕｈ＝＃ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃ Ｇｄｗｈ＝＃ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃

；３３１３４＃Ｓｊ＃４＃