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2. Date of Application
   Date of Application
4. Name of Permittee
6. Address of Permittee
8. City
9. State
10. Zip
12. Phone Number
13. Emergency Contact
15. Contractor (if applicable)
17. Type of Development

    1. New
    2. Existing
    3. Residential

    1. Commercial
    2. Road Improvement
19. Location of Work
21. Subdivision / Development / Federal
23. Project Number
25. Description of Work
27. Proposed Starting Date
    Proposed Starting Date
28. Proposed Completion Date
    Proposed Completion Date
30. Agreement
    A. The permittee hereby agrees to restore and replace such street, avenue, boulevard, road, alley, public easement or highway disturbed or affected, and to conduct all work in accordance with the approved plan(s) and the requirements. The Chief Inspector of St. Charles County shall be notified 24 hours prior to commencement of work at 636-949-7305, for any construction questions and upon job completion for final inspection.
    
    B. The permittee hereby acknowledges its responsibility to incur all costs, which may result from damages to applicant's facilities at the location described herein, which may be caused by maintenance, construction, reconstruction, signing and any other work lawfully performed by the St. Charles County Highway Department upon the county right-of- way over, under or across the location described herein.
    
    C. The permittee agrees to perform all work in accordance with this permit and to indemnify and hold harmless St. Charles County, its officers, agents and employees from all liability, judgments, costs, expenses and claims growing out of damage, or alleged damages of any nature to any person or property arising out of performance or nonperformance of said work or the existence of facilities and/or appurtenances thereof.
    
    I have read the "Requirements to Work in County Right-of-Way" (PDF) document.
32. Signature
    By typing or signing my name, I acknowledge that I have read and agree to follow the above conditions and attached Requirements to Work on County Right-of-Way. An electronic signature shall be as valid and binding as an original signature.
34. Permittee's Signature
35. Company Name
37. Date
    Date
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39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

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