APPLICATION AND AGREEMENT

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APPLICATION AND AGREEMENT Powered By Docstoc
					                                   INSTRUCTIONS
                               TRIPLE TRAILER PERMIT


1. Complete Permit.

2. This is an annual permit.

3. This permit is only available to companies who hold or seek a permit to operate triple
   trailers on the Indiana Toll Road.

4. The destination must be on a City of South Bend truck route, and the path on the way to
   the Toll Road must follow truck routes and must be no longer than seven and one-half
   (7.5) miles.

5. Include the route from and to the toll road you plan to take through South Bend.

6. Signature and contact information is required.

7. Return permit to:

   Board of Public Works
   227 West Jefferson
   1316 County-City Building
   South Bend, Indiana 46601
    (574) 235-9251
   Fax: (574) 235-9171
   E-mail: publicwks@southbendin.gov
                                                             SPECIAL PERMIT

                                      TO OPERATE LONG COMBINATION VEHICLES
                                        TO AND FROM THE INDIANA TOLL ROAD


Name of Transporting Company: __
Name of Representative: _                 _                  Title: _          _
Headquarters Address:            _
Telephone: _             _                                   Fax: _            _
Name of Local Representative: _                    _
Address of Local Terminal:               _        _
Telephone: _             _                                   Fax: _            _
The transporting company, in possession of a valid Gate Permit to operate long double and/or triple tractor-trailer
combinations on the Indiana Toll Road, is hereby authorized to operate such combinations on City of South Bend
streets along the shortest route on which the vehicle can safely maneuver from the Indiana Toll Road as described
below. All general and special conditions of the Gate Permit shall apply while on South Bend streets. This permit
shall be valid twenty-four hours per day, every day, except that the transporting company agrees to suspend
operations on City of South Bend streets at such times that emergency conditions prohibits safe travel. The
transporting company shall make each and every operator of such combination vehicles aware of this permit and its
conditions. The transporting company agrees to indemnify, defend, exculpate, and hold harmless the City of South
Bend, Indiana, its officials and employees from any liability due to loss, damage, injuries, or other casualties of any
kind, including attorney fees arising out of, or resulting from, the issuance of this permit. The transporting company
understands that the City of South Bend does not warrant, guarantee, nor hold forth that the streets along this route
are currently in condition to accommodate such combinations.

The representative of the transporting company signing below certifies that he holds the title stated and that he is
authorized by the company to bind the company to these conditions.

_________________________________             _       _                   Title_      __             Date: _       _
Signature                                     Printed Name
Route:__    __


The return trip to the Indiana Toll Road shall be reversed, except as noted above. The length of the (one way) trip is
_      _ miles.

Operation of long combination vehicles on City of South Bend streets according to the
terms stated above and along the route given is hereby approved for a period not to exceed
one year from the date approved.
 Notification of approval/denial of this request will be issued by return of this form, upon signed authorization
 by the Board of Public Works.

RETURN FORM TO:                              FOR CITY USE ONLY                  Board of Public Works
                                             RECOMMENDATIONS             APPROVED      DENIED, Please see attached
Board of Public Works
                                             Police Department
1316 County-City Building
                                             Legal                    ______________________
227 West Jefferson Boulevard                                          Gary A. Gilot, President
                                             Other
South Bend, IN 46601
Phone: (574) 235-9251                                                 ______________________
                                                                      Don E. Inks, Member
Fax: (574) 235-9171
E-Mail: publicwks@southbendin.gov                                     ______________________
                                                                      Carl P. Littrell, Member
                                                                      Attest:
                                                                      Date: __________      Linda M. Martin, Clerk

				
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posted:12/14/2011
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