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DPW Form -36(1) 6/15/2011 County of Hawaii DEPARTMENT OF PUBLIC WORKS — ENGINEERING DIVISION SIDEWALK USE PERMIT PERMITTEE: PHONE NO.: MAILING ADDRESS: EMAIL: PROPOSED USE OF SIDEWALK (* Note: All commercial uses are prohibited): DESCRIPTION OF ITEM(S) THAT WILL BE PLACED IN THE COUNTY RIGHT -OF -WAY: LOCATION OF ITEM(S) — ATTACH LOCATION MAP: Illr_X:411•r_IN1110 � Name of County Road /Street DURATION(Dates): From: to (Not to exceed 1 year) (Times): From: (am/ pm) to (am /pm) DIMENSIONS OF ITEM AND SIDEWALK (OR ATTACH SKETCH SHOWING DIMENSIONS): 1. WIDTH OF SIDEWALK (curb face to back edge of sidewalk): feet 2. WIDTH OF WIDEST ITEM (at widest point): feet 3. CLEAR WIDTH OF SIDEWALK (width of sidewalk — width of widest item): feet (3 feet minimum) 4. HEIGHT OF ITEM: feet (4 feet maximum) REQUIRED ATTACHMENTS: 1. Location map showing the item(s), the sidewalk and all other objects in the area including utility pole signs, etc. [Hawai`i County Code section 22- 3.7(2)] 2. Statements of consent from all property owners and lessees directly fronting the item(s). [Hawai`i County Code section 22- 3.7(7)] 3. Provide a certificate of insurance and proof of a public liability insurance policy naming as an additional insured, the county, its officers, representatives, employees, and agents covering any claim or liability for damages, injuries or death resulting from any of the uses permitted hereunder. The minimum amount of coverage under such policy shall be $1,000,000 per occurrence. The policy and coverage shall be kept in force until the proposed use is terminated and the permitted items are removed from the County Street. [Hawai`i County Code section 22- 3.7(9)] IN CONSIDERATION OF GRANTING THIS PERMIT, THE PERMITTEE UNDERSTANDS AND AGREES TO: Hold harmless, indemnify and defend the County of Hawai'i; its officers, employees and agents thereof from all claims, demands, suits, actions, or proceedings of every name, character, and description which may be brought against the County of Hawaii for or on account of any injuries or damages to any person or property received or sustained by any person by or in consequence of any act or acts of the holder of this permit for actions done under this permit. [ Hawai'i County Code section 22- 3.7(8)]; and Comply with all conditions as printed on the back of this permit. [Hawai`i County Code section 22 -3.9]. By signing below, the Permittee certifies that the Permittee has legal authority to sign in the capacity stated, and the Permittee understands and agrees that the terms and conditions of this permit are a legally binding contract. By: EMO Permittee's Signature Director, Department of Public Works Date Date AGENCY USE ONLY PERMIT NO: FEE: $25 County of Hawai'i is an Equal Opportunity Provider and Employer