Land Use Permit Application - In Place Utility (New Street Acceptance) Form

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LAND USE PERMIT
LUP-IPP
Land Use Permit Application – In Place Utility (New Street Acceptance)
August 22, 2014
APPLICATION is hereby made for an in-place permit for utilities installed on subdivision streets to be accepted into the
secondary system of state highways and as described below. Said activity(s) has been done under and 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 agreement between the parties herein before referred to. Applicant agrees to maintain
work in an approved manner. Applicants to whom permits are issued shall at all times indemnify and save harmless
the Commonwealth Transportation Board, members of the Board, the Commonwealth and all Commonwealth
employees, agents, and offices, from responsibility, damage, or liability arising from the exercise of the privileges
granted in such permit to the extent allowed by law.
APPLICANT SHALL RECEIVE AN IN-PLACE PERMIT AT NO COST
Application should accompany Subordination of Rights or Quitclaim Agreement, if such agreement is necessary
TYPE OR PRINT CLEARLY
Utility Company Name: _____________________________________________ Tax ID No.: _______________________
Mailing Address: __________________________________________ Contact Name: ____________________________
City: __________________________________ State: ______ Zip Code: __________ E-mail Address: ________________
Telephone Number: ( ____ ) _______-____________
Fax Number: ( _____ ) _______-__________
SUBDIVISION NAME: _________________________________________________ Plan Approval Date: _______________
Geographically located in County / Town / City of: ________________________ Connecting to Highway Route No.: ______
Type of utility (electrical, cable TV, telephone, water, sewer, gas):________________________________________________
Utility lines have been installed as shown on above-noted subdivision plan within the right-of-way of the following streets:
STREET NAME
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Signature of Applicant: _________________________________ Title: ______________________ Date: ______________

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