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CE -7W <br />Rev. 9/90 <br />Land Use Permit Application No. <br />19745 <br />Commonwealth of Virginia Department of Transportation <br />"PPUCATION is hereby made for permit as shown on the accompanying plan or sketch and as described below. Said work and or activity (s) will be done under <br />nd in accordance with the rules and regulations of the Commonwealth Transportation Board of Virginia, in so far as said rules are applicable thereto and any <br />agreement between the parties hereinbefore referred to. Where applicable agreements maybe attached and made a pertof the permit assembly including any <br />cost responsibilities covering work under permit. Applicant agrees to maintain work in a manner as approved upon its completion. Applicant also hereby agrees <br />and is bound and held responsible to the owner for any and all damages to any other installations already in place as a result of work covered by resulting permit. <br />Applicants to whom permits are issued shall at all times indemnity and save harmless the Commonwealth Transportation Board members of the Board, the <br />Commonwealth, and all Commonwealth employees, agents, and officers, from responsibility, damage, or liability arising from the exercise of the privileges <br />granted in such permit. In consideration of the issuance of a permit the applicant agrees to waive for itself, successors in interest or assigns any entitlements it <br />may otherwise have or have hereafter under the Uniform Relocation and Assistant Act of 1972 as amended in the event the Department or its successor, <br />chooses to exercise its acknowledged right to demand or cause the removal of any or all fixtures, personalty of whatever kind or description that may hereafter <br />be located, should this application be approved. <br />Applicant: TYPE OR PRINT CLEARLY <br />9��o7�a0�¢\ltsed+Q�1o8��v <br />CITY OF CHARLOTTESVILLE <br />Filing date <br />Owner <br />GAS DIVISION <br />Permit term needed 180 days <br />Agent <br />V�Q\VEp <br />P. 0. Box 911 <br />Total fees enclosed $ <br />Address <br />Charlottesville, VA 22902 <br />MethodofPayment Check—Coupons-M.O.— <br />City State zip Code <br />Other (Specify) <br />54750018K <br />Surety Information: <br />Social Security Number or Tax ID Number <br />( 804 1 293-9164 <br />Name Resolution <br />Phone Number <br />Kent McElhenv, Superintendent <br />Amount$ 999,999,999.00 <br />Contact Person <br />•( 804 ► 980-9817 <br />Account# CVA000404 <br />Fax Number <br />The estimated cost of this work is $ <br />Obligation Amount $ <br />Bond — LC _ ResolutionX Ord. — Check — Not <br />Applicable — <br />A <br />Request Permission: To perform the following work and/or activity (s): \ to l \� R O- <br />oIQ <br />\ N <br />tJdt..3 ok..l V -r7 ad be <br />'• l OWt •t' o� t- 0 4n <br />G V C <br />M n as per attached plans. <br />Location: Tax Map Number <br />Permittee Job No. <br />Geographically in County/Town/C" rty of Albemarle <br />on ��Iighway Route(s) 4 ,e w <br />between 1/,4 ROJ4 866 <br />and L%/F cTbunr /04F� <br />c <br />Signature of applicant or agentA Date q O6 <br />Title Su erintendent <br />All applicable items on this form must be completed before your request can be considered. Recheck information furnished to <br />avoid delay. Prepayment Required - make Remittance payable to Virginia Department of Transportation. <br />VDOT USE ONLY <br />•Receipt is hereby acknowledged of CHECK COUPON M.O. —, OTHER (Specify) <br />$ (Permit Fee $ CASH SURETY $ <br />Signed <br />VDOT <br />White Copy to Central Office Pink Copy to Residency Office Blue Copy to District Office Yellow Copy to Applicant <br />in the amount of <br />