ࡱ>  UWJKLMNOPQRST} bjbj55 @__-LL$; ;.w#w#w#w#:*p-/99999997<>90(N:*009w#w#u: 8 8 80bRw#w#9 809 8 8" 8w#` ]2 89:0 ; 8?2? 8? 800 800000997F000 ;0000?000000000L U: Application to Occupy Right of WayApplicant: (Name and Address) Date: FORMTEXT       FORMTEXT       Phone: FORMTEXT       Fax No.: FORMTEXT       Email: FORMTEXT      TypeWith aSizeMaterial Type FORMCHECKBOX  Overcross FORMCHECKBOX  Water Line  FORMTEXT       FORMTEXT       FORMCHECKBOX  Undercross FORMCHECKBOX  Sewer Line  FORMTEXT       FORMTEXT       FORMCHECKBOX  Occupy FORMCHECKBOX  Gas Line  FORMTEXT       FORMTEXT       FORMCHECKBOX  Miscellaneous FORMCHECKBOX  Telephone Line   FORMCHECKBOX  Underground   FORMCHECKBOX  Aerial  FORMTEXT       FORMTEXT       FORMCHECKBOX  Temporary Irrigation Pipe Crossing (Remove by October 15th this year)  FORMTEXT       FORMTEXT       FORMCHECKBOX  Electric Line   FORMCHECKBOX  Underground   FORMCHECKBOX  Aerial FORMTEXT      If aerial, type of Section:  FORMCHECKBOX  Ditch  FORMCHECKBOX  Curb  Speed Limit:  FORMTEXT    mph FORMCHECKBOX  Tree Trimming/Tree Removal  FORMCHECKBOX  Grading  FORMCHECKBOX  Other Location: beginning FORMTEXT      feet East  FORMCHECKBOX  West  FORMCHECKBOX  North  FORMCHECKBOX  South  FORMCHECKBOX  of the East  FORMCHECKBOX  West  FORMCHECKBOX  North  FORMCHECKBOX South  FORMCHECKBOX  Line of Section FORMTEXT      , Township FORMTEXT      North, Range FORMTEXT      East  FORMCHECKBOX  West  FORMCHECKBOX  of the 6thP.M., FORMTEXT      County, Nebraska. This is also FORMTEXT      feet East  FORMCHECKBOX  West  FORMCHECKBOX  North  FORMCHECKBOX  South  FORMCHECKBOX  of MilepostNo. FORMTEXT      on the East  FORMCHECKBOX  West  FORMCHECKBOX  North  FORMCHECKBOX  South  FORMCHECKBOX  side of Highway No. FORMTEXT      . If the application is to  occupy, the work extends  FORMTEXT      feet East  FORMCHECKBOX  West  FORMCHECKBOX  North  FORMCHECKBOX  South  FORMCHECKBOX . Requirements: The applicant agrees to complete this work in accordance with the terms and conditions of the Nebraska Department of Roads. Any permit issued will be cancelled if the work specified is not completed within the term listed on the permit or within any additional length of time granted. Request for an extension of time to complete the work must be made in writing. Any extension granted will be acknowledged in writing by the Nebraska Department of Roads. The Applicant may cancel the permit with written notification at any time prior to beginning work on highway right of way. Performance Guarantee: (Make payable to Nebraska Department of Roads)Amount: $ FORMTEXT      Check/Account No.  FORMTEXT      Name and Address: FORMTEXT      This guarantee is for the faithful compliance by the Applicant to the terms of the permit. It is understood that should the Applicant fail to perform the work as set forth in the permit, the State will have the right to keep the performance guarantee as liquidated damages for its necessary supervisory and inspection expenses and to initiate such legal proceedings as are necessary to secure either performance of the work in compliance with the terms of the permit or the restoration of the highway right of way to its previous condition prior to the activities of the Applicant.  NOTE: Please complete the appropriate location plan attached for overcross or undercross of location to occupy state right-of-way. When your project requires engineering plans, please submit four sets of plans, no larger than 12 x18 . The engineering plans shall show the general features of the work to be completed and all information such as sizes, distances, dimensions, cuts and fills, erosion control measures, etc., when applicable.Name (Please Print)Applicants SignatureRecommended ByDateDistrict Engineer ApprovalDateDistrict Recommendations:  FORMTEXT      DR Form 19, Jan 08 Location Plan for Overcross or Undercross (4 copies to be included with application) Note: All applicants must use this plan and fill in the required information.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX SectionTownshipRangeCounty FORMCHECKBOX Indicate North MilepostMilepostsection linesection lineDistance to closest milepost FORMTEXT       Ft. FORMTEXT       Ft.No.  FORMTEXT      No.  FORMTEXT      CenterlineHwy. 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$$Ifa$gdP4444444444444444444444444444 $$Ifa$gdP $IfgdP4444444444444444444444444444Ff $IfgdP444444444444444444444445555Ff $IfgdP $$Ifa$gdP555555 5 5 5 5 555555555555555555 $$Ifa$gdP $IfgdP55 5!5"5#5$5%5&5'5(5)5*5+5,5-5.5/505152535455565758595:5Ff  $IfgdP:5;5<5=5>5?5@5A5B5C5D5E5F5G5H5I5J5K5L5M5N5O5P55 0<^`0gd.KFf $$Ifa$gdP $IfgdP5555|``adabb&b(b*b,b.b0b2b4b6b8b$$If]^a$$If]^$ 0^`0a$gd[# $xa$gd] $<a$gd.K @^`@gd.Kl description, including section, township, range, and county ( Designate North direction Location Plan to Occupy State Right of Way (4 copies to be included with application) Note: All applicants must use this plan and fill in the required information.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX SectionTownshipRangeCounty FORMCHECKBOX Indicate North x--- x--- x--- x--- x--- x--- x--- x--- x--- x--- x--- x--- x--- x -ROW ---x--- x--- x--- x--- x--- x--- x--- x--- x--- x--- x--- x--- x--- x section lineDistance from ROW to Work Areasection line FORMTEXT       Ft.Distance from Work Area to Centerline FORMTEXT       Ft.Work Area  Starting Point Total Length of Work Area Starting Point  FORMTEXT       Ft.   Centerline    Hwy No. FORMTEXT       FORMTEXT       Ft.    Total Length of Work Area      FORMTEXT       Ft. FORMTEXT       Ft.    Distance to nearest section line   MilepostMilepost - x - -- x --- x --- x --- x --- x --- x -- - x --- ROW --- x --- x --- x --- x --- x - -- x --- x --- x --- x --- x --- x --- x -           FORMTEXT       Ft. FORMTEXT       Ft.     Distance from Starting Point of Work Area to Closest Milepost  No.  FORMTEXT      No.  FORMTEXT           Note: The following information is required on all plans: ( Highway number ( Distance in feet to nearest section line ( Distance in feet to nearest milepost ( Distance in feet to State ROW ( Distance in feet to centerline ( Total length of work area ( Complete legal description, including section, township, range, and county ( Designate North direction  bbb b"b$b:bbZb\b^b`bdbfbhbbbbbbbbbbbbbbbbbbo]"jhFCu5CJOJQJUaJ%j$hFCuCJOJQJUaJ%j~$hFCuCJOJQJUaJ%j hFCuCJOJQJUaJ%jA hFCuCJOJQJUaJ*jhFCuCJOJQJUaJmHnHu%j}hFCuCJOJQJUaJjhFCuCJOJQJUaJhFCuCJOJQJaJ 8b:b`bfbbbbbbbbbbbbbbbbbcc@c$$If]^a$Ffs"$If]^$$If]^a$Ff6bccccccc.c0c2ccBcDcXcZc\cfchclcncccc˴˴˴xkSx.j&h<hFCu5CJOJQJUaJh<5CJOJQJaJ"jh<5CJOJQJUaJ(jP&hFCu5CJOJQJUaJ(j%hFCu5CJOJQJUaJ-jhFCu5CJOJQJUaJmHnHu"jhFCu5CJOJQJUaJ(jh%hFCu5CJOJQJUaJhFCu5CJOJQJaJ@cBcjclcccccccccdddd$d&d(dLdNdFf-$$If]^a$$If]^$$If]^a$Ff($$If]^a$ccccccccccccccc$d(d*dFdHdJd`d|d~ddeɽzgZzNhFCuCJOJQJ^JhL-&6CJOJQJaJ%j/hFCuCJOJQJUaJhFCu6CJOJQJaJ%j+hFCuCJOJQJUaJ%jG+hFCuCJOJQJUaJjhFCuCJOJQJUaJhFCuCJOJQJaJhFCu5CJOJQJaJ"jh<5CJOJQJUaJ-jh<5CJOJQJUaJmHnHuNdPdRdTdVdXdZd\d^d`d~ddddddddd$$If]^a$Ff?1$If]^dddkdJ3$$IfTl4 P @ x s= H H  t4$$$$44 laf4Tee"e*e~eeeee0fFf`fgg*g,g.g8g:gBghggXhZh\hph}fO-jhjA5CJOJQJUaJmHnHu-jhFCu5CJOJQJUaJmHnHu(jMhFCu5CJOJQJUaJhFCu5CJOJQJaJ"jhFCu5CJOJQJUaJhFCu5CJOJQJ\aJhFCuCJOJQJaJhFCuCJOJQJaJhFCuCJOJQJ^Jh'h'5CJOJQJ^Jh'CJOJQJ^Jdeeeeeeeeeeeeeeeeeeeeee0f2f4f $($Ifa$$Ifqq$If]q^qgd3AC h4f6f8f:ff@fBfDfFf`fbfdfffhfjflfnfpfrftfvfxfzf|f~ffFf7$qq$If]q^qa$$IffffffffffffffffffffffffffffffFf-@$IffffffffffffffffffffffffffffffFf@H$Ifffffffffggggg g gggggDgFgHgJgLgNgPgRgTgVg $$Ifa$$IfVgXgZg\g^g`gbgdgfghggggggggggggggggggg $($Ifa$FfS$Ifggggggggggggggggggggghhhhh h hhFfl_$Ifhhhhhhhhh h"h$h&h(h*h,h.h0h2h4h6h8h:hh@hBhDhFhFfg$IfFhHhJhLhNhPhRhThVhXhhhhhhhhhhhhhhhhhh$x$Ifa$gd/{OFfp$Ifphrhth~hhh.i0iDiVijjlRlTlVl`lbljlٵzzkzzٵVٵ(jhFCu5CJOJQJUaJhFCu5CJOJQJ\aJhFCuCJOJQJaJhFCu5OJQJ\aJ*jhFCuCJOJQJUaJmHnHuhFCuCJOJQJaJhFCu5CJOJQJaJ-jhFCu5CJOJQJUaJmHnHu"jhFCu5CJOJQJUaJ(j5uhFCu5CJOJQJUaJhhhhhhhhhhhhhhhhhhhhhhhhhhhhhFfy$Ifhhhhhhhhhhhhhhhiiiii i iiiiiiiii$Ifii i"i$i&i(i*i,i.i2i4i6i8i:ii@iBiDiXiZi\i^i`ibidifi $$Ifa$Ff&$Iffihijilinipiritivixizi|i~iiiiiiiiiiiiiiiiiFf$IfiiiiiiiiiiiiiiiiiiiiiiiiiiiiiFfĞ$Ifiiiiiiiiiiiiiiiiiiiiijjjjj j jjj$Ifjjjjjjjj j"j$j&j(j*j,j.j0j2j4jOkdK$IfK$L$0 ( t(4a$IfK$$If4j6j8j:jj@jBjDjFjHjJjLjNjPjRjTjVjXjZj\j^j`jbjdjfjhjjjljFf$Ifljnjpjrjtjvjxjzj|j~jjjjjjjjjjjjj$IfK$$IfjjjjjjjjjjjjjjjjjjjjFf$IfOkd$IfK$L$0 ( t(4ajjjjjjjjjjjjjjjjjjjjkkkkk k kkk$If $$Ifa$kkkkkkkk k"k$k&k(k*k,k.k0k2k4kFfOkd_$IfK$L$0 ( t(4a$IfK$$If4k6k8k:kk@kBkDkFkzk|k~kkkkkkkkkkkkkkkk$IfK$ $$Ifa$$IfkkkkkkkkkkkkkkkkkkkFf$IfOkdK$IfK$L$0 ( t(4a$IfK$kkkkkkkkkkkkkkkkkklllll l ll$IfK$ $$Ifa$$Iflllllllll l"l$l&l(l*l,l.l0l2l4lFfb$IfOkd>$IfK$L$0 ( t(4a4l6l8l:lm@mBmDmFmHm$IfK$ $$Ifa$$IfHmJmLmNmPmRmTmVmlmnmpmrmtmvmxmzm|m~mm $$Ifa$Ff$IfOkd2$IfK$L$0 ( t(4ammmmmmmmmmmmmmmmmmmmmmmmmm$IfK$$If $$Ifa$mmmmmmmmmmmmmmmmmmm $$Ifa$Ffx$IfOkd $IfK$L$0 ( t(4ammmmmmmmmmmmmmmmmmmmmnnnnn n nn$IfK$$Ifnnnnnnnnn n"n$n&n(n*n,n.n0n2n4nFf$IfOkd$IfK$L$0 ( t(4a4n6n8n:nn@nBnDnFnHnJnLnNnPnRnTnVnXnZn\n^n`nbndnfnhnjnlnnn$Ifnnpnrntnvnxnzn|n~nnnnnnnnnnnFf:/Okd&$IfK$L$0 ( t(4a$IfK$$Ifnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn$IfnnnnnnnnnnnnnnnnnnnnnnnnnnoooFf!>$Ifooo o oooooooooo o"o$o&o(o*o,o.o0o2o4o6o$IfK$$If6o8o:oo@oBoRoTo|o~ooooooo $$Ifa$ $$Ifa$FfJ$IfOkdE$IfK$L$0 ( t(4a|oooooooooooooDpFppppppq2qqqqqqrrɴ֝vj^jRhFCuCJOJQJaJhlCJOJQJaJhlCJOJQJaJh 5CJOJQJ\aJh CJOJQJaJh CJOJQJaJ-jhC5CJOJQJUaJmHnHu(jQhC5CJOJQJUaJhC5CJOJQJaJ"jhC5CJOJQJUaJhCCJOJQJaJhCCJOJQJaJoooooooooooooooooooooo$IfK$$If $$Ifa$gdCooooooooooooooopppppFf=W$IfOkd4R$IfK$L$0 ( t(4ap p pppppppppp p"p$p&p(p*p,p$IfK$$If,p.p0p2p4p6p8p:pp@pBpDpFpHpJpLpNpPpRpFfb$IfOkd^$IfK$L$0 ( t(4aRpTpVpXpZp\p^p`pbpdpfphpjplpnppprptpvp$IfK$$Ifvpxpzp|p~ppppppppppppppppFfn$IfOkdi$IfK$L$0 ( t(4appppppppppppppppppppppppppp$IfK$$IfppppppppppppppppppppFfx|$IfOkdu$IfK$L$0 ( t(4apppppq4q6q8q:qq@qBqDqFqHqJqLqNqPqRqTqVqXq