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District Six 6/95 DATE: SECTION NO: COUNTY: STATE PROJECT NO. APPLICANT: ADDRESS: _ CITY: _ TELEPHONE NO ATTACINENT "B " STATH OF FLORIDA DEPARTMENT OF TRANSPORTATION SPHCIAL PERMIT PERMIT NO.: STATE ROAD NO.: _ MILEPOST FROM: _ (if applicable) RECORD NO.: STATE: TO: ZIP CODE: Applicant requests permission from the State of Florida Department of Transportation, hereinafter called the Department, to construct, operate, and maintain the facility shown in the accompanying engineering as described here: Location of Construction, Street Name, and Nearest Intersection: 1. Is the proposed work within the corporate limits of a municipality: Yes ( ) No ( ) Name of municipality: Local Government Contact: 2. Prior to filing this application, the location of all existing utilities, both aerial and underground, has been ascertained, and the accurate locations are shown on the drawings (as applicable). A letter of notification was mailed on _ _ _ _ _ t o t h e f o 1 1 o w i n g utilities/municipalities: 3. It is expressly stipulated that this permit is a license for permissive use only and that the construction within and/or upon public property pursuant to this permit shall not operate to create or vest any property right in said holder. 4. Whenever it is determined by the Department that it is necessary for the construction, repair, improvement, maintenance, safe and/or efficient operation, alteration, or relocation of any or all portion of said highway and/or transportation facility; the Permittee shall immediately remove any and all installed facilities from said highway and/or transportation facility, or reset or relocate thereon as required by the Department at the Permittee's expense. 5. All work shall meet Department's Roadway and Traffic Desicin Standards, Specifications for Road and Bridge Construction, and other applicable criteria in effect at the time of permit issuance. The work shall be performed under the inspection supervision of , Permit/Maintenance Engineer located at , Telephone No. This designated engineer shall be notified forty-eight (48) hours prior to the pre - construction meeting and again immediately before commencement of work. All material and equipment shall be subject to inspection by the designated engineer or his authorized representative. 6. All Department property shall be restored to its original condition as far as practical in keeping with Department Specifications, and in a manner satisfactory to the Department, within thirty (30) days of the installation of the permitted work, unless otherwise approved by the Department. 7. A drawing covering details of this work shall be made a part of this permit. This drawing shall include plan, profile, and cross sections as appropriate, and may be required to bear the seal of a professional engineer licensed in the State of Florida. As built drawings are required: Yes ( ) No ( ) 8. The Permittee shall commence actual construction in good faith within days from the date of said permit approval and shall compete construction within days from the commencement of work unless the permittee shows good cause for delay and the Department approves an extension. No extension beyond one (1) year from the date of issuance of this permit will be granted. 9. This construction and maintenance shall not interfere with the property and rights of a prior Permittee. 10. Special Conditions and Instructions by the Department: 11. It is understood and agreed that the rights and privileges herein set out are granted only to the extent of the State's right, title, and interest in the land to be entered upon and used by the Permittee, his heirs, assigns, and successors in interest, and the Permittee will, at all times, assume all risk of and indemnify, defend, and save harmless the State of Florida and the Department from and against any and all loss, damage, cost, or expense arising in any manner on account of the exercise or attempted exercise by said Permittee of the aforesaid rights and privileges. 12. During construction through Department acceptance of the permitted work, all safety regulations of the Department shall be observed and the holder must take measures, including placement and display of safety devices, that may be necessary in order to safely conduct the public through the project area in accordance with the Department's current edition of the Roadway and Traffic D sian Standard , Index Series 600, and the Manual of Uniform Traffic Control Devices. 13. In case of non-compliance with the Department's requirements in effect as of the approved date of this permit, this permit is void and the work will be brought into compliance or removed from the right-of-way at no cost to the Department. Submitted and Agreed to by: Corporate Seal Signature of Permittee Name and Title (typed) Attested Recommended for approval: Title: Date: Approved by: Date: District Permit Engineer or Authorized Representative SUNYISLE.AG 1 1