OFFICE USE ONLY

RIGHT OF WAY PERMIT APPLICATION Township

CALHOUN COUNTY ROAD COMMISSION Permit Number
13300 15 Mile Road - Marshall, MI 49068
Date Issued
Phone (269) 781-9841 (800) 781-5512 Fax (269) 781-8223
www.calhouncrc.net Expiration Date
Receipt Number

If applicant hires a contractor to perform the work, BOTH parties must complete this form and BOTH assume responsibility for the provisions of this
application and permit.

APPLICANT OWNER DEVELOPER OTHER CONTRACTOR

NAME: NAME:

ADDRESS: ADDRESS:

CITY, STATE, ZIP: CITY, STATE, ZIP:

PHONE / FAX: PHONE / FAX:

Applicant agrees to and will adhere to the conditions stipulated on the front and reverse side of this application, as well as, all specifications listed on
the permit when issued. Issuance of this permit does not imply consent for use of the land that may be inconsistent with other local, township,
county, state and/or federal ordinances and does not negate the need for other such permits. This permit is good for one year from issue date.

Applicant Signature Date

Contractor Signature Date
INSURED:  YES  NO
ATTACHMENTS:  YES  NO
Special Instructions:

Applicant and/or Contractor requests a permit, and agrees to the terms of the permit listed on the back of this form, for the purpose indicated in the
attached plans and specifications at the following location:
TOWNSHIP SECTION

NAME OF ROAD BETWEEN AND

FOR A PERIOD BEGINNING AND ENDING

PLEASE CHECK THE APPROPRIATE CATEGORY:

Seismic Testing $126.00
Temporary Road Closure-Single Day Permit $163.80
Miscellaneous Right-of-Way $ 94.50
Detour Routes Varies
$13.20 per mile per day
UTILITY
Single Day Permit $ 63.00
Annual Blanket Permit (Utilities & Surveyors) $315.00
Overhead & Underground Utility Permits $126.00
Plus $.05 per linear foot
Road Bore $126.00
Tapping County Storm Sewer $945.00
Bituminous Roadcut/Replaced by CCRC $2,024.40
Includes minimum replacement of 110 sq ft.

Additional Bituminous replacement per sq ft. $ 18.13

Bituminous Roadcut/Replaced by Utility Company $378.00
Gravel Road Cut $252.00

Total Cost $

Right Of Way Permit Application/elc/12/29/2008

1. Specifications. All work performed under this permit must be done in accordance with the plans, specifications, maps and statements filed with
CCRC* and must comply with CCRC current requirements and specifications on file at their offices and / or M.D.O.T. specifications. CCRC
will not be held responsible for any facilities that do not conform to these specifications which are damaged by CCRC staff in the regular course
of work.

2. Fees and Costs. Permit Holder shall be responsible for all fees incurred by CCRC in connection with this permit and shall deposit estimated
fees and costs as determined by CCRC at the time the permit is issued.

3. Insurance. Permit Holder shall furnish a certificate of liability and property damage insurance showing that coverage is in effect for the
person/organization who will be shaping the access. This certificate of insurance will show a coverage of a minimum of $500,000 as required
by CCRC. The certificate of insurance must contain the following language: “Additional insured with regard to Liability Coverage: Calhoun
County Road Commission, Board of County Road Commissioners, its officers, agents, and employees, 13300 15 Mile Road, Marshall, MI
49068”. Such insurance shall cover a period not less than the term of this permit and shall provide that it cannot be canceled without ten (10)
days advance written notice by certified mail with return receipt required to CCRC.

4. Indemnification. Permit Holder shall hold harmless and indemnify and keep indemnified CCRC, its officers and employees from all claims,
suits and judgments to which CCRC, its officers, or employees may be subject and for all costs and actual attorney fees which may be incurred
on account of injury to persons or damage to property, including negligence of the Permit Holder and CCRC arising out of the work under this
permit, or in connection with work not authorized by this permit, or resulting from failure to comply with the terms of this permit, or arising out
of the continued existence of the work product which is the subject of this permit.

5. Safety. Permit Holder agrees to work under this permit in a safe manner and to keep the area affected by this permit in a safe condition until the
work is completed. All work site conditions shall comply with Michigan Manual of Uniform Traffic Control Devices.

6. Notification of Start and Completion of Work. Permit Holder must notify CCRC at least 48 hours before starting work and must notify
CCRC when work is completed.

7. Time Restrictions. All work shall be performed Monday through Friday between 8 a.m. and 5 p.m. unless written approval is obtained from
CCRC and work shall be performed only during the period set forth in this permit.

8. Restoration and Repair of Road. Permit Holder agrees to restore the road and right-of-way to a condition equal to or better than its condition
before the work began; and to repair any damage to the road right-of-way which is the result of the facility whenever it occurs or appears.

9. Limitation of Permit. This permit does not relieve Permit Holder from meeting other applicable laws and regulations of other agencies.
Permit Holder is responsible for obtaining additional permits or releases which may be required in connection with this work from other
governmental agencies, public utilities, corporations and individuals, including property owners. Permission may be required from the
adjoining property owners.

10. Revocation of Permit. This permit may be suspended or revoked at will, and the Permit Holder shall surrender this permit and alter, relocate or
remove its facilities at its expense at the request of the commission.

11. Violation of Permit. This permit shall become immediately null and void if Permit Holder violates the terms of permit, and CCRC may require
immediate removal of Permit Holder’s facilities, or CCRC may remove them without notice at Permit Holder’s expense.

12. Assignability. This permit may not be assigned without the prior approval of CCRC. If approval is granted, the assignor shall remain liable
and the assignee shall be bound by all the terms of this permit.

13. Further Requirements. This permit is subject to supplemental specifications on file with CCRC and Act 200 of Public Acts of 1969.

*Calhoun County Road Commission

Right Of Way Permit Application/elc/12/29/2008