The under signed here with makes application for a permit to enter upon and use portions of dedicated-rights-of-way of the Town of Camp Verde, here in after designated as the Town, for the purpose of:

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Location of work:_____________________________________________________________________________________

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FOR AND IN THE CONSIDERATION of the granting of a permit for the purpose set forth here in the Permittee as follows, to wit:

1. That the Permittee assume the responsibility and all liability for any injury or damage within said rights-of-way, or to any persons using said rights-of-way in a lawful manner, caused by or arising out of the exercise of this permit.

2. That all work should be at the sole cost and expense of the Permittee and shall be done in such time in such manner as to be the least inconvenient to the traveling public. Work must be finish within the time specified on the permit.

3. Prior to beginning work permitted here on, notice shall be given to the Town at least 24 hours prior to beginning of work. Notice shall also be given to the Town upon completion of permitted work. These notices shall be delivered to the Town at the Camp Verde Street Department, 395 S. Main Street, Camp Verde, AZ. 86322, telephone (928) 567-0534 or Town Hall, 473 S. Main Street, Camp Verde, AZ. 86322, telephone (928) 567-6631.

4. The Town reserves the right to require pre-construction conference and a final inspection with all parties concerned on any work permitted, which is designated as a major project by the Town Engineer. At the time of final inspection, any work not completed will be brought into compliance with the permit requirements within 30 days, or all permits to the Permittee shall be null and void, and any bond or guarantee to the Town for completion of this work shall become the property of the Town.

5. Any deviation from the approved plans attached to the permit shall require prior approval from the Town Engineer; otherwise all permits to the Permittee shall become null and void and all bonds or guarantee forfeited to the Town.

6. That Permittee will not permit or allow any of his property remaining in the rights-of-way to be a hazard or source of danger to the traveling public.

7. The Permittee shall furnish a bond or other financial guarantee, satisfactory to the Town of Camp Verde, for a sum sufficient to repair or replace any failure of the surface replacement due to materials and workmanship of the Permittee for a period of two years from completion and approval by the Town of such work. The amount of this bond shall be determined by the Town at the time of issuing the permit. No permit shall be issued without posting this bond.

8. That in the event the work to be done under the authority of the Permittee necessitates the creation of any hazard or source of danger to any person or vehicle using said rights-of-way, said Permittee shall provide, and maintain at all times during the existence of said hazard, sufficient traffic controls, barriers, barricades, cones, signs, lanterns, detours, flagmen etc. as required by the current United States Department of Transportation, Federal Highway Administration, Manuel on Uniform Traffic Control Devices, and shall take such other measures of precaution as is necessary under the existing circumstances.

9. Time Schedule-

(a) Permit shall be in effect for 30 days from date of issue.

(b) Construction time of permit for an ordinary cut ditch shall be 2 days.

(c) On large construction projects, the permit shall be in effect for the life of the contract as specified

in the permit.

10. Fees- an inspection fee shall be charged for all permits requiring inspection, with the expectation of driveways and

driveway culverts, and said fee shall be as follows:

(a) An inspection fee of $10.00 for each and every inspection necessary requiring no more than one hour of inspection time.

(b) For inspections requiring more than one hour, the fee shall be based on a $12.00 per man hour unit.

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All work performed under permit granted by this form shall be performed in accordance with the Town's Standards.

(a) Any and all work performed within Town right-of-way and/or a Town maintained road shall require a permit from the Town Engineer's office and shall be subject to whatever inspections that shall be deemed necessary by the Town Engineer.

(b) The backfilling of all ditches or excavations shall be inspected and approved by the Town Engineer or his representative.

(c) The Permittee shall replace all signs moved or damaged during construction.

(d) Only rubber tired equipment shall be used on pavement, except that crawler equipment using street pads may be used with permit obtained from the Town Engineer's office.

(e) During the course of work, the Permittee shall maintain the work area in a clean and orderly condition. Excess excavation, debris, etc., will not be permitted to accumulate on the road surface or shoulders. Work shall progress in such manner that no conditions such as soft trenches, drop-offs from the edge of pavement, etc., will exist. Upon completion of installation, the Permittee shall clean the pavement surface, pull and dress shoulders, and otherwise put in order the entire work area covered by the permit to the satisfaction of the Town Engineer or his representative.

IN WITNESS WHERE OF this application has been duly signed this ________ day of_______________, _________.

Applicant's Signature___________________________________________

Applicant's Name (Please Print) _________________________________

Mailing Address______________________________________________

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Phone______________________________________________________

THIS APPLICATION is approved with the following requirements:

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Date Received & Approved Camp Verde Town Engineer

Effective Date of Permit:_______________ Date Work Begun:__________________________________

Inspected By:________________________ Date:____________ Inspection Time: ___________________

Inspected By:________________________ Date:____________ Inspection Time:____________________

Inspected By:________________________ Date:____________ Inspection Time:____________________

Date Work Completed:________________ Total Inspection Time:__________________________________

Trench excavation, backfilling and compaction shall be in accordance with Section 601.1 to Section 601.4.6 of the M.A.G. Specifications.

Asphalt concrete pavement replacement shall be constructed in accordance with Standard Detail CV200D or CV201D, and as required by Section 321 and 710. "T" Top replacement may be initially waived by the Town but may be required prior to final approval if unusual conditions or poor construction practices so warrant.

Section 601.5.1 - GRADING: The Permittee shall do such grading in the area adjacent to backfilled trenches and structures as may be necessary to leave the area in a neat and satisfactory condition approved by the Town.

Section 601.5.2 - RESTORING SURFACE: All streets, alleys, driveway, sidewalks, curbs or other surfaces which have been broken into or damaged by the installation of new work shall be resurfaced as specified on the Permit, otherwise to be resurfaced in kind in accordance with Section 336.

Section 601.5.3 - CLEANUP: The job site shall be left in neat and acceptable condition. Excess soil, concrete, etc., shall be removed from the premises.

Section 601.5.4 - TEMPORARY PAVEMENT: The Permittee shall install temporary asphalt pavement or the first course of permanent pavement replacement in accordance with Section 336 immediately following backfilling and compaction of trenches that have been cut through existing pavement. Except as otherwise provided in Section 336, this preliminary pavement shall be maintained in a safe and reasonably smooth condition until required backfill compaction is obtained. Temporary pavement removed shall be hauled from the job site and disposed of by the Permittee. Installation of temporary pavement, may be waived by the Town at the time of application for permit if the Town feels such waiver would not be detrimental to the completed surface restoration.

Section 601.5.5 - RESTRICTION TO OPEN CUTTING OF PAVEMENT: No open cut for utilities shall be permitted in any improved Arterial or Major Collector roadway without the specific approval of the Town Council.

Section 601.5.6 - UTILITY CUTS IN RECENTLY IMPROVED ROADWAYS: No cutting of pavement for the installation of utilities shall be permitted within one year from the completion of roadway surfacing consisting of a 2" or greater thickness of asphaltic concrete pavement. The Town will advise all interested utility agencies prior to such surfacing of roadways and provide them an opportunity to plan and install necessary utility lines prior to the roadway improvements.

Section 601.5.7 - POSTED BOND: The Permittee shall furnish a bond or other financial guaranty, satisfactory to the Town of Camp Verde, for a sum sufficient to repair or replace any failure of the surface replacement due to materials or workmanship of the Permittee, for a period of one year from completion and approval by the Town of such work. The amount of this bond shall be determined by the Town, at the time of issuing the permit. No permit will be issued without posting this bond.