#FFFFFF Applicant Name First and Last Name Phone Email Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Authorized Representative Title of Authorized Representative Description of Work Description of the work including route, total distance, and equipment to be used. Proposed Work Schedule Proposed Traffic Control Be it understood by Applicant that this Permit, when issued, is valid only in those right-of-ways under the jurisdiction of Dolores County. Applicant must obtain separate permits to work within right-of-ways under the jurisdiction of the State or other municipalities. If the requested permit is granted, Applicant agrees: To take every precaution to protect the highway, traffic, pedestrians, County infrastructures, and other ROW installations from damage or injury. To be financially responsible, indemnify and hold the County harmless, and to make prompt payment for any damage, actual or claimed, related to actions by Applicant pursuant to the Permit. To act consistently with the specifications and conditions of the Permit, as well as Dolores County Resolution Number 01-20-01, state law, and federal law. The County does not guarantee the width of any ROW. Permittee, as well as Owners and Operators shall be solely responsible, at their own expense, to defend and/or relocate installations ultimately determined to be outside the County ROW. Submit
