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DPW Form COUNTY OF HAWAI'I <br /> 33(1)Rev DI I'%RI III \I Of I'( HI.1('WORK' - 1 \(,I\FI.R1\(: DIVISION <br /> 04-10•2015 PERMIT TO WORK WITHIN THE COUNTY <br /> RIGHT-OF-WAY <br /> CHECK ALL APPLICABLE BOXES <br /> ❑ Construct new driveway approach Type of Driveway' 0 Asphalt Driveway Use: 0 Commercial <br /> ❑ Resurface/repair existing driveway approach 0 Concrete 0 Residential <br /> ❑ Construct or repair sidewalk <br /> ❑ Other(describe work) <br /> WIDTH OF APPROACH/DIMENSION OF WORK: FT x FT ESTIMATED COST: $ <br /> _-.__— TAX MAP KEY: <br /> Name of County Road 1 Street <br /> START DATE COMPLETION DATE WORKING HRS. <br /> (Minimum two working days after approval) (Monday thru Friday) <br /> PERMITTEE: <br /> MAILING ADDRESS. PHONE NO <br /> CONTRACTOR <br /> MAILING ADDRESS PHONE NO. <br /> LICENSE NO: <br /> IN CONSIDERATION OF GRANTING THIS PERMIT,THE PERMITTEE UNDERSTANDS AND AGREES <br /> TO:(Permittee to initial each line below) <br /> Agree to hold harmless. indemnify and defend the County of Hawaii,its officers,employees and agents thereof,from all claims, <br /> demands,suits,actions,or proceedings of every name,character and description which may be brought against the County of Hawaii for <br /> or on account of any injuries or damages to any person or property received or sustained by any person by or in consequences of any <br /> act or acts of the holder of this permit for actins done under this permit[Hawaii County Code Section 22-4.2(7)). <br /> Submit with this permit a certificate of insurance and proof of a public liability insurance policy naming as an additional insured, the <br /> County. Its officers, representatives,employees,and agents covering any claim or liability for damages, injuries or death resulting from <br /> any of the uses permitted hereunder The minimum amount of coverage under such policy shall be $1,000,000 per occurrence. The policy <br /> and coverage shall be kept in force until all work under this permit is completed to the satisfaction of the director of the department of public <br /> works. [Hawaii County Code Section 22-4 2(8));and <br /> Comply with all conditions as printed on the back of this permit [Newai'i County Code Section 22 4.4). <br /> Byinittaling above and signing below,the Permittee certifies that the Permittee has legal authority to sign in the capacity stated, and the <br /> Permittee certifies that the Permittee has legal authority to sign In the capacity stated,and the Permittee understands and agrees that <br /> the terms and conditions of this permit are a legally binding contract. <br /> By: <br /> AGENCY USE ONLY <br /> Permitee'a Signature Date Final Acceptance Date: <br /> Its. By ----- <br /> _ Inspectors Signature <br /> APPROVED: Comments. <br /> -- — PERMIT NO: FEE: • <br /> Director,Department of Public Works i y y Date <br /> County ol-Ifavrti'i i9 nn Tqual Opportunity Providei and Uinployar <br />