Applicant Information:

Application is hereby made to the Douglas County Engineer by:

* required fields

Project Information:

TO*:
(DESCRIBE TYPE OF WORK APPLICANT WISHES TO PERFORM)

LOCATION*:
(DESCRIPTION OF COUNTY RIGHT-OF-WAY)

All detailed information such as locations, elevations, cuts, fills, distances and dimensions shall be shown on applicants plans submitted to Douglas County.

I (we) agree to perform the work in accordance with the permit which may be issued as a result of the application within * days months from the date of issuance of a permit. This permit may be canceled any time by the applicant prior to construction of the work.

NOTE: In the event future highway construction or maintenance requires an alteration, relocation or removal of the work authorized in this permit, the applicant shall perform such work as requested and without expense to Douglas County. Where applicant has been notified that highway construction or maintenance will begin and applicant fails to perform the required work which was obligated under this permit, the permit will be automatically revoked. Where upon Douglas County will have all rights to remove any structure, appurtenances or do any other acts of removal or reshaping in regard to the County Right-of-Way and may, at its option, charge the costs to the applicant. Applicant will not be entitled to damages for such revocation of the permit or the removal of the structures erected under this permit.

I agree all above is correct, and realize checking this box is a legal substitute for signing this form.