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DPW Form -35(1) County of Hawaii 1/10/2012 DEPARTMENT OF PUBLIC WORKS ENGINEERING DIVISION PUBLICATION DISPENSER PERMIT PERMITTEE: PHONE NO.: MAILING ADDRESS: EMAIL: LOCATION OF PUBLICATION DISPENSER — ATTACH LOCATION MAP: Name of County Road /Street DURATION (dates): From: to DIMENSIONS OF PUBLICATION DISPENSER AND SIDEWALK (OR ATTACH SKETCH SHOWING DIMENSIONS): 1r_X:40TAr_IZI1110 (Not to exceed 1 year) 1. WIDTH OF SIDEWALK (curb face to back edge of sidewalk): ft 2. WIDTH OF PUBLICATION DISPENSER (at widest point): ft 3. CLEAR WIDTH OF SIDEWALK (width of sidewalk —width of publication dispenser): ft (3 ft min) 4. HEIGHT OF PUBLICATION DISPENSER: ft (4 ft max) REQUIRED ATTACHMENTS: Location map showing the County Street, the publication dispenser, the sidewalk and all other objects in the area including utility poles, signs, etc. [ Hawai'i County Code Section 22- 3.5.(2)] Statements of consent from all property owners and lessees directly fronting the publication dispenser. [Hawai'i County Code Section 22 -3.5. (6)] 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 banner, including all anchors, supports and other appurtenances are removed from the county right -of -way. [Hawai'i County Code Section 22- 3.5.(8)] IN CONSIDERATION OF GRANTING THIS PERMIT, THE PERMITTEE UNDERSTANDS AND AGREES TO: Hold harmless, indemnify and defend the County of Hawaii, 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- 3.5.(7)]; 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 Permitee's Signature Its Director, Department of Public Works Date Date AGENCY USE ONLY * Pay by Check payable ONLY to: County D °rector of Rnance PERMIT NO: FEE: $25 County of Hawai'i is an equal opportunity provider and employer