LUP-CS cash surety affidavit provided for cash surety?
Request permission to perform the following activity(s) as per attached plan:
Permit term requested:
Estimated cost of work to be performed on VDOT Right of Way:
Name of city, town or county:
From route number:
From route name:
To route number:
To route name:
Tax map number:
Applicant job number:
APPLICATION is hereby made for permit as shown on the accompanying plan or sketch and as described below. Said activity(s) will be done under and in accordance with the rules and regulations of the Commonwealth Transportation Board of Virginia, in so far as said rules are applicable thereto and any agreement between the parties herein before referred to. Where applicable agreements may be attached and made a part of the permit assembly including any cost responsibilities covering work under permit. Applicant agrees to maintain work in a manner as approved upon its completion. Applicant also hereby agrees and is bound and held responsible to the owner for any and all damages to any other installations already in place as a result of work covered by resulting permit. Applicants to whom permits are issued shall at all times indemnify and save harmless the Commonwealth Transportation Board members of the Board, the Commonwealth and all Commonwealth employees, agents, and offices, from responsibility, damage, or liability arising from the exercise of the privileges granted in such permit to the extent allowed by law. In consideration of the issuance of a permit the applicant agrees to waive for itself, successors in interest or assigns any entitlements it may otherwise have or have hereafter under the Uniform Relocation and Assistant Act of 1972 as amended in event the Department or its successor, chooses to exercise its acknowledged right to demand or cause the removal of any or all fixtures, personality of whatever kind or description that may hereafter be located, should this application be approved.
If applicable, I agree to pay the full salary and expenses of a state assigned inspector in conjunction with activities authorized under the auspices of a VDOT Land Use Permit.
I hereby certify that I fully understand and agree to comply with all of the requirements associated with the Land Use Permit application, that I have the authority to make the foregoing request, and that the information provided is correct.
Enter your initials to confirm the accuracy of the above information and submit the application for review.