State Form 41769 PDF Details

The State 41769 form serves as a crucial document for those seeking a right-of-way permit from the Indiana Department of Transportation. It is a comprehensive form that covers various types of projects such as excavation, pole line, bridge attachment, and miscellaneous works within the state of Indiana. The form, sanctioned by the State Board of Accounts and the Auditor of State in the year 2000, mandates applicants to provide detailed information about the project location, description, purpose, and any associated bond details if required. Additionally, it outlines the financial responsibilities, including permit fees and any potential costs related to inspections by the Department of Transportation. Applicants must agree to indemnify and hold harmless the State of Indiana, its officials, and employees from any liabilities that may arise from the project, emphasizing the importance of safety and compliance. The form inherently requires the permit holder to adhere to specific guidelines during the execution of their project, including maintaining signage, avoiding interference with existing structures, and conforming to established construction specifications. The permit is subject to inspection and can be rescinded if found non-compliant, underscoring the state's dedication to maintaining safety and order within its right-of-ways. The guidelines of the State 41769 form aim to streamline the permit process while ensuring that projects carried out within the state's jurisdiction meet the required standards and regulations, thus protecting both the public interest and the integrity of Indiana's transportation infrastructure.

QuestionAnswer
Form NameState Form 41769
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names2000, R5, ISSUANCE, authorizations

Form Preview Example

 

RIGHT OF WAY PERMIT

 

 

 

STATE OF INDIANA

 

 

 

 

 

 

 

State Form 41769 (R5 / 3-00)

 

 

 

INDIANA DEPARTMENT OF TRANSPORTATION

 

 

 

 

 

 

 

Approve by State Board of Accounts, 2000

 

 

 

Approved by Auditor of State, 2000

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Permit:

 

 

 

 

 

 

 

Excavation

Pole Line

Bridge Attachment

Miscellaneous

 

 

 

 

 

 

District

 

Subdistrict

 

Telephone number

 

 

 

 

(

 

)

 

Project locations:

 

 

 

Reference pt. number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Project description:

 

 

 

 

 

 

 

Project purpose:

Bond required:

 

If Yes, Penal Sum

Bond number

 

 

 

Yes

 

No

$

 

 

 

 

 

 

PERMIT FEE: (Make check or bank draft payable to "Indiana Department of Transportation")

$

SPECIAL PROVISIONS:

THE APPLICANT AGREES TO INDEMNIFY, DEFEND, EXCULPATE, AND HOLD HARMLESS THE STATE OF INDIANA, ITS OFFICIALS AND EMPLOYEES FROM ANY LIABILITY DUE TO LOSS, DAMAGE, INJURIES, OR OTHER CASUALTIES OF WHATSOEVER KIND, OR BY WHOMSOEVER CAUSED, TO THE PERSON OR PROPERTY OF ANYONE ON OR OFF THE RIGHT-OF-WAY ARISING OUT OF, OR RESULTING FROM THE ISSUANCE OF THIS PERMIT OR THE WORK CONNECTED THEREWITH, OR FROM THE INSTALLATION, EXISTENCE, USE, MAINTENANCE, CONDITIONS, REPAIRS, ALTERATION, OR REMOVAL OF ANY EQUIPMENT OR MATERIAL, WHETHER DUE IN WHOLE OR IN PART TO THE NEGLIGENT ACTS OR OMISSIONS (1) OF THE STATE, ITS OFFICIALS, AGENTS, OR EMPLOYEES; OR (2) OF THE APPLICANT, HIS AGENTS, OR EMPLOYEES, OR OTHER PERSONS ENGAGED IN THE PERFORMANCE OF THE WORK, OR (3) THE JOINT NEGLIGENCE OF ANY OF THEM; INCLUDING ANY CLAIMS ARISING OUT OF THE WORKMEN'S COMPENSATION ACT OR ANY OTHER LAW, ORDINANCE, ORDER, OR DECREE. THE APPLICANT ALSO AGREES TO PAY ALL REASONALBE EXPENSES AND ATTORNEY'S FEES INCURRED BY OR IMPOSED ON THE STATE IN CONNECTION HEREWITH IN THE EVENT THAT THE APPLICANT SHALL DEFAULT UNDER THE PROVISIONS OF THIS PARAGRAPH.

Signature of permit applicant

Printed name of permit applicant

 

 

 

Name of company organization

 

Telephone number

 

 

(

)

Address (number and street, city, state, ZIP code)

Inspector

District Regulatory Supervisor

District Director

Application number

Road number

County number Expiration date Issue date

Permit number

State of Indiana

Department of Transportation

GENERAL PROVISIONS

1.All work described in the permit shall be subject to the inspection of the Department of Transportation and the permittee shall adjust or stop operations upon direction of any police officer or Department of Transportation employee.

2.The permit may be rescinded at any time by the Department of Transportation at its discretion or for noncompliance with any and/or all provisions of said permit.

3.The permittee shall notify the Department of Transportation Subdistrict five (5) working days preceding the beginning of any work activity.

4.The permittee shall notify the Department of Transportation Subdistrict that the work is complete and this notice is to be provided within seven (7) days from completion of all work on this permit.

5.The permittee shall have the permit complete with drawings and special provisions in their possession during work operations and will show said permit on demand, to any police officer or authorized Department of Transportation employee.

6.The permittee shall pay the Department of Transportation for any inspection costs where it is necessary to assign a Department of Transportation employee to inspect the work. The permittee shall immediately reimburse the State upon receipt of an itemized statement.

7.The permit is valid through the stated expiration date. If work is not completed within the allotted time, the permit is automatically cancelled unless an extension is requested prior to the expiration date and said request is approved by the Department of Transportation. If a permit is cancelled, a new application must be submitted and approved before the proposed work can be accomplished.

8.The permittee shall erect and maintain all necessary signs, barricades, detour signs, and warning devices required to safely direct traffic over or around the part of the highway where permitted operations are to be done so long as the work does not interfere with traffic, in accordance with Section “VI” of the Indiana Manual of Uniform Traffic Control Devices.

9.All construction and materials used within the highway right-of-way must conform to the current Department of Transportation “Standard Specifications” with the permittee being considered in the same status as the contractor.

10.The permitted operations shall not interfere with any existing structure on the Department of Transportation right-of-way without specific permission in writing from the Department of Transportation. In the event that any buildings, railings, traffic control devices, or other structures are damaged, said cost of the removal and/or damage shall be borne by the permittee.

11.This permit does not apply to any State roads or bridges that are closed for construction purposes, or to any county roads or city streets.

12.Approval of the permit application shall be subject to the permittee obtaining all necessary authorizations from local authorities and complying with all applicable laws. The issuance of the permit shall in no way imply Department of Transportation approval of, or be intended to influence any action pending before a local board, commission, or agency.

13.The permitted operations shall be allowed on state highway right-of-way only between sunrise and sunset and shall not be performed on Saturdays, Sundays, or during the period beginning at 12:00 Noon on the last weekday (Monday through Friday) preceding and continuing until Sunrise on the day following: New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving, and Christmas.

14.In accordance with the notice requirements of Indiana Code 4-22-1-25, any objection to the conditions and provisions of an approved permit must be submitted in writing to the Department of Transportation within fifteen (15) days from the issue date.

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