OFFICE USE ONLY DRIVEWAY PERMIT APPLICATION CALHOUN COUNTY ROAD COMMISSION 13300 15 Mile Road - Marshall, MI 49068

Phone (269) 781-9841 (800) 781-5512 - Fax (269) 781-8223 www.calhouncrc.net
Township Permit Number Date Issued Expiration Date Receipt Number

*HOMEOWNER
NAME: ADDRESS: CITY, STATE, ZIP: PHONE / FAX: EMAIL ADDRESS

DEVELOPER

OTHER

CONTRACTOR
NAME: ADDRESS: CITY, STATE, ZIP: PHONE / FAX: EMAIL ADDRESS

Applicant agrees to and will adhere to the conditions stipulated on the front and reverse side of this application, as well as, all specifications listed on the permit when issued. Issuance of this permit does not imply consent for use of the land that may be inconsistent with other local, township, county, state and/or federal ordinances and does not negate the need for other such permits. This permit is good for one year from issue date. Applicant will provide a drawing of the site showing proposed access(es).

Applicant Signature Contractor Signature

Date Date

*If homeowner, please provide homeowners insurance information, IF known for location noted on this permit. *Homeowners insurance carrier: Policy number: Location Street Number (if known) Located (Feet or Miles) (N, S, E or W) Please check the appropriate category:
New Residential Access Inspection Only Total Cost$63.00 $56.70 $

Street Name of (Closest Intersection)

on the (N, S, E or W) Township

side.

 Is this access request a result of a LAND DIVISION. If so please attach an approval from the appropriate
department.  Special Instructions:
1) CCRC policy requires culvert installation for driveways countywide. 2) Applicant will provide a drawing of the site showing proposed access(es). 3) Access must slope away from road ½ inch per foot, a minimum of four (4) feet or the width of existing shoulder, whichever is greater. 4) Thoroughly read the back of the permit. The permit is good for one year from the permit issue date. 5) Staking Instructions are as follows: Place two (2) stakes four and one half (4 1/2 ) feet tall at proposed driveway location twenty (20) feet apart. Label the stakes “CCRC Drive”. Please make sure that stakes are in place twenty (24) hours after applying for permit.
Driveway Permit Application/elc/12/29/2008

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Specifications. All work performed under this permit must be done in accordance with the plans, specifications, maps and statements filed with CCRC* and must comply with CCRC current requirements and specifications on file at their offices and / or M.D.O.T. specifications. This permit is valid for one year from the actual Permit issue date. Any driveway, which is not created or hard surfaced within this timeframe, must have an additional permit in order for further work to be executed. Insurance. Permit Holder shall furnish a certificate of liability and property damage insurance showing that coverage is in effect for the person/organization who will be shaping the access. This certificate of insurance will show a coverage of a minimum of $500,000 as required by CCRC. The certificate of insurance must contain the following language: “Additional insured with regard to Liability Coverage: Calhoun County Road Commission, Board of County Road Commissioners, its officers, agents, and employees, 13300 15 Mile Road, Marshall, MI 49068”. Such insurance shall cover a period not less than the term of this permit and shall provide that it cannot be canceled without ten (10) days advance written notice by certified mail with return receipt required to CCRC. *If homeowner, please provide homeowners insurance information on the front of the application. Indemnification. Permit Holder shall hold harmless and indemnify and keep indemnified CCRC, its officers and employees from all claims, suits and judgments to which CCRC, its officers, or employees may be subject and for all costs and actual attorney fees which may be incurred on account of injury to persons or damage to property, including negligence of the Permit Holder and CCRC arising out of the work under this permit, or in connection with work not authorized by this permit, or resulting from failure to comply with the terms of this permit, or arising out of the continued existence of the work product which is the subject of this permit. Restoration and Repair of Road. Permit Holder agrees to restore the road and right-of-way to a condition equal to or better than its condition before the work began; and to repair any damage to the road right-of-way, which is the result of the facility whenever it occurs or appears. Limitation of Permit. This permit does not relieve Permit Holder from meeting other applicable laws and regulations of other agencies. Permit Holder is responsible for obtaining additional permits or releases which may be required in connection with this work from other governmental agencies, public utilities, corporations and individuals, including property owners. Permission may be required from the adjoining property owners. Revocation of Permit. This permit may be suspended or revoked at will, and the Permit Holder shall surrender this permit and alter, relocate or remove its facilities at its expense at the request of CCRC. Assignability. This permit may not be assigned without the prior approval of CCRC. If approval is granted, the assignor shall remain liable and the assignee shall be bound by all the terms of this permit. Further Requirements. This permit may not be assigned without the prior approval of CCRC and Act 200 of Public Acts of 1969. Miss Dig. The Permit Holder must comply with the requirements of Act 53 of Public Acts of 1974, as amended. CALL MISS DIG AT (800)482-7171 AT LEAST THREE (3) FULL WORKING DAYS, BUT NOT MORE THAN TWENTY-ONE (21) CALENDAR DAYS, BEFORE YOU START WORK. Permit Holder assumes all responsibility for damage to or interruption of underground utilities.

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10. Safety. Permit Holder agrees to work under this permit in a safe manner and to keep the area affected by this permit in a safe condition until the work is completed. All work site conditions shall comply with Michigan Manual of Uniform Traffic Control Devices. 11. Violation of Permit. This permit shall become immediately null and void if Permit Holder violates the terms of permit, and CCRC may require immediate removal of Permit Holder’s facilities, or CCRC may remove them without notice at Permit Holder’s expense. 12. A new permit is required on an existing drive if a structure has been removed, demolished or other and if a new residence will be moved, constructed or other. *CALHOUN COUNTY ROAD COMMISSION

Driveway Permit Application/elc/12/29/2008

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