Access & Use of Highway Department Lands Permit

Date of Application: City/Town/Village: Reason for Request: Property Location: From: To: Applicant's Name: Applicant's Address: Applicant's Phone: Date of Proposed Usage: Start Time: End Time: Map of Area or Route (Please attach a detailed sketch of the proposed affected area or route.): Detailed Action Plan (Who, what, when, why, where, how and safety information): I agree to enforce the traffic control for this area/route, and I understand local law enforcement will be contacted for any deviation from the signed plan and may issue citations as a result: YesNo Special Requirements and Restrictions:

The above applicant hereby requests permission to use Kewaunee County Highway Department property as described above, per the action plan and the assigned map with all fees and paperwork completed prior to work starting. Additionally, the applicant agrees to, and will abide by, the conditions listed below. Permission must be obtained from the Highway Board to use County Highway property. Permission must also be granted by the Highway Commissioner to temporarily use the Kewaunee County Highway property. The Commissioner reserves the right to terminate the agreement at any time for violations of the agreement or misuse based on the terms of the agreement.

APPLICATION CONDITIONS
 
1. The applicant shall accept full responsibility for the use of the highway property and it shall make no claims against the County by reason of their use. 

2. The applicant shall minimize as much as practicable the duration and use of this property providing for security and cleanup of all affected areas returning them to previous condition. 

3. The applicant shall be responsible for any and all traffic and control measures consisting of appropriate and adequate marking, signing, barricading, and security on the site. Any operation must not hinder, block, or obstruct any county equipment, facilities, or access to county assets.
 
4. The applicant shall provide a specific notice to the County as to the location(s), dates and times of all work to be performed from the site. 
 
5.  The applicant shall secure adequate insurance, not less than $1,000,000 (one million) dollars to protect against liability exposure related to subject usage. As a requirement of this permit, a Certificate of Liability Insurance document MUST accompany the application/permit in order to be valid. 
 
6.  Applicant/Permittee, successors, and assignees agree to hold Kewaunee County, its agent, and employees harmless against any action for personal injury or property damage sustained by reason or exercise of this permit.
 
7. Fees will be based on the published Kewaunee County Fee Schedule. These are standard charges for general access and the County may additionally invoice the customer for any services or work required on behalf of this request or for restoration of area being used.
 

*NOTE: Submittal of this form constitutes a signature, confirms the accuracy of the data provided, and provides agreement to the terms in the disclaimer.