Land Use Permit - LUP-UT
Utility installations
The installation of utilities on state maintained highway right-of-way is authorized under Sections 24VAC30-151-300
General
Provisions Governing Utilities through 24VAC30-151-400 of the Land Use Permit Regulations
http://law.lis.virginia.gov/admincode/title24/agency30/chapter151/
Land Use Permit Required by Law
The General Rules and Regulations of the Commonwealth Transportation Board provide that no work of any nature shall be
performed on any real property under the ownership, control, or jurisdiction of VDOT until written permission has been obtained
from VDOT. Written permission is granted for the installation of utilities
on state maintained highway right-of-way
thr
ough the issuance of a land use permit.
By issuing a permit, VDOT is giving permission only for whatever rights it has in the right-of-way; the permittee is responsible for
obtaining permission from others who may also have an interest in the property.
The permittee will be civilly liable to the Commonwealth for expenses and damages incurred by VDOT as a result of violation of any
of the rules and regulations of this chapter. Violators shall be guilty of a misdemeanor and, upon conviction, shall be punished as
provided for in §33.2-210
of the Code of Virginia.
Application Requirements
Application for a land use permit authorizing the installation of utilities on non-limited or limited access state maintained highways
shall be made through the local district permit office where the activity is to take place.
The proposed installation shall accompany plan/sketches showing distances from edge of pavement, existing and proposed right-of-
way line, depths below existing and proposed grades, depths below ditch line or underground drainage structures, or other features
shall be shown. Any existing utilities within close proximity of the permittee's work shall be shown. Location of poles, guys,
pedestals, relief valves, vent pipes, etc. shall be shown. Height of wires or cables above the crown of the roadway shall be shown.
Please note the company has to be registered with the State Corporation Commission and with Miss Utility.
Application, forms and general information regarding VDOT land use permitting for the installation of utility on state maintained
highways right-of-way are included below.
24VAC30-151-710. Fees.
A. Single use permit. A nonrefundable application fee shall be charged to offset the cost of reviewing and processing the permit
application and inspecting the project work, in accordance with the requirements below:
1. The application fee for a single permit is $100.
2. Additive costs shall be applied as indicated below.
Activity Fee
Storm Sewer $10 per 100 linear feet
Box Culvert or Bridge $5 per linear foot of attachment
Drop Inlet $10 per inlet
Pole Attachment $10 per structure
Span Guy $10 per crossing
Additive Guy and Anchor $10 per guy and anchor
Underground Utility - Parallel $10 per 100 linear feet
April 1, 2017
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Activity Fee
Overhead or Underground Crossing $10 per crossing
Excavation Charge (including Test Bores and Emergency
Opening)
$10 per opening
Surety Requirement
The permittee and/or their agent shall provide surety to guarantee the satisfactory performance of the activity authorized under the
auspices of the land use permit issued for the initial installation. The surety shall be based on the estimated cost of work to be
performed within the right-of-way and the amount shall be determined by the district administrator’s designee. The surety may be in
the form of a check, cash, irrevocable letter of credit, Corporate Surety, Resolution or bond. This surety will be refunded or released
upon satisfactory completion of the initial installation and inspection by VDOT.
Cash Surety Refund
Applicants owing the Internal Revenue Service or the Commonwealth of Virginia may not receive a refund of the cash guarantee
provided for the issuance of a VDOT land use permit unless the amount owed is less than the amount of cash guarantee provided.
Applicants providing cash guarantee for the issuance of a VDOT land use permit must provide an executed copy of the
Commonwealth of Virginia’s Substitute Form W-9 to receive a refund of the cash guarantee provided for the issuance of a VDOT
land use permit
Contact Information
A list of counties with their corresponding VDOT district offices and contact information may be obtained at the following VDOT web
site: http://www.virginiadot.org/about/districts.asp
Land Use Permit Application (LUP-A)
APPLICATION is hereby made for permit as shown on the accompanying plan or sketch and as described below. Said activity(s) will be 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. Where applicable agreements may be attached and made a part of the permit assembly including any cost responsibilities covering work under permit.
Applicant agrees to maintain work in a manner as approved upon its completion. Applicant also hereby agrees and is bound and held responsible to the owner for any and all
damages to any other installations already in place as a result of work covered by resulting permit. 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. In consideration of the issuance of a permit the applicant
agrees to waive for itself, successors in interest or assigns any entitlements it may otherwise have or have hereafter under the Uniform Relocation and Assistant Act of 1972
as amended in event the Department or its successor, chooses to exercise its acknowledged right to demand or cause the removal of any or all fixtures, personality of
whatever kind or description that may hereafter be located, should this application be approved
.
Applicant information:
Driver’s License or Tax ID No. _________________________ Contact Name ____________________________________________
Owner Name ________________________________________________ E-mail Address __________________________________________
Address ____________________________________________________ Telephone Number _______________________
City ________________________State ______Zip Code_____________ Emergency Telephone Number _______________________
Fax Number _______________________
Agent information:
Driver’s License or Tax ID No. _________________________ Contact Name ____________________________________________
Owner Name ________________________________________________ E-mail Address __________________________________________
Address ____________________________________________________ Telephone Number _______________________
City ________________________State ______Zip Code_____________ Emergency Telephone Number ________________________
Fax Number _______________________
Permit Term Requested ___________ Fees Enclosed $ ___________ Check Number ____________ Money Order ____________
Estimated cost of work to be performed on VDOT Right of Way $_____________________
Surety Information:
Surety Posted by: Owner Agent County Resolution Waived
Bonding Company Name _____________________________ Bond # _________________
Irrevocable Letter of Credit - Bank Name ____________________________ Irrevocable Letter of Credit # _________________
Surety paid by Check - Check Number ________________
Amount of Surety $ ____________________ Obligation Amount $_________________
Request permission to perform the following activity(s): ________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________as per attached plans.
Location: County Town City of __________________________ Route No. ________ Street Name _____________________________
Between Route No. _________ Street Name _________________________ and Route No._________ Street Name ___________________________
Latitude _________________ Longitude__________________ Tax Map Number _______________________ Applicant Job No.__________________
Applicant shall provide proof of registration as an operator with the appropriate notification center in accordance as defined in §2.2-1151.1 of the Code of Virginia & must provide a notarized
affidavit, stating that the utility owner has notified the commercial and residential developer, owner of commercial or multifamily real estate, or local government entities with a property
interest in any parcel of land located adjacent to the property over which the land use is being requested, that application for the permit has been made.
IF APPLICABLE, I AGREE TO PAY THE FULL SALARY AND EXPENSES OF A STATE ASSIGNED INSPECTOR IN CONJUNCTION WITH ACTIVITIES AUTHORIZED
UNDER THE AUSPICES OF A VDOT LAND USE PERMIT.
By signing below, I acknowledge that I am fully cognizant of all the LUP-SPG requirements associated with the issuance of a VDOT Land Use Permit.
Signature of Applicant: _____________________________________________ Title __________________________ Date ___________________
Signature of Agent: ________________________________________________ Title __________________________ Date ___________________
All applicable items on this form must be completed to avoid delay in processing the issuance of a VDOT Land Use Permit.
Prepayment required with remittance payable to Virginia Department of Transportation.
VDOT USE ONLY
Receipt is hereby acknowledged for: CHECK No.: ___________________________ MONEY ORDER No.: ______________________________
In the Amount of $ _________________________ for PERMIT FEE $ _________________________ CASH SURETY $ _________________________
Authorized VDOT Signature: ____________________________________________________ Date: ____________________________________
*Agent mean: Applicant contractor’s or a person or business authorized to act on another's behalf.
If cash/check surety is posted, please complete
Commonwealth of Virginia’s Substitute Form W-9
.
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Land Use Permit
LUP-SPG
Special Provisions General
Permittee Agreement for Land Use Permit
Issuan
ce
Any of the following provisions that may apply, shall apply:
General Requirements
1) Permittee acceptance and use of a Virginia Department of Transportation (VDOT) land use permit is prima facie evidence that
the permittee has read and is fully cognizant of all required permit provisions, applicable traffic control plans and associated
construction standards to be employed. All 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 officers, from responsibility, damage, or liability arising from the exercise of the privileges granted in
such permit to the extent allowed by law including any sums ordered to be paid or expended by VDOT by any governmental
entity as a fine, penalty or damages for any violation of any applicable environmental law, or to remediate any hazardous or
other material, including illicit discharge into VDOT maintained storm sewer systems.
2) The permittee assumes full responsibility for any and all (downstream flooding, erosion, siltation, etc.) damages that may occur
as a result of the work performed under this permit. Furthermore, the Department will in no way be responsible for any
damage to the facility being placed as a result of future maintenance or construction activities performed by the Department.
3) The permittee agrees to move, remove, alter, or change any installation that interferes with the ultimate construction of the
highway in alignment or grade at no cost to the Department unless otherwise stipulated and agreed to by the Department.
4) The permittee shall immediately correct any situation that may arise as a result of these activities that the district
administrator’s designee deems hazardous to the traveling public.
5) Any and all highway signs, right-of-way markers, etc., disturbed as a result of work performed under the auspices of a land use
permit shall be accurately reset by the permittee immediately following the work in the vicinity of the disturbed facility. The
services of a certified land surveyor with experience in route surveying may be required.
6) It shall be the permittee's responsibility to obtain any and all necessary permits that may be required by any other government
agencies, i.e., U.S. Army Corp. of Engineers, Department of Environmental Quality, Department of Conservation and Recreation,
etc.
7) A copy of the VDOT land use permit shall be maintained at the work site and made readily available for inspection when
requested by authorized VDOT personnel.
8) The permittee shall notify the local district permit office at least 48 hours prior to commencement of any work requiring
inspection and/or testing as stipulated in VDOT’s Road and Bridge Standards (current edition) and VDOT’s Road and Bridge
Specifications (current edition). Failure to carry out this requirement may result in permit revocation.
9) The permittee or their agent must contact the VDOT Customer Service Center at 1-800-367-7623 a minimum of 48 hours prior
to initiating any planned excavation within 1,000 feet of a signalized intersection and/or near VDOT ITS infrastructure.
Excavation activities may proceed only after the VDOT regional utility location agent has notified the permittee that the utility
marking has been completed. Additional information can be found at:
http://www.virginiadot.org/business/resources/IIM/TE-383_Request_for_Marking_VDOT_Utility_Location.pdf
Alternately, within all localities in the Northern Virginia Construction District, including the Counties of Arlington, Fairfax,
Loudoun & Prince William, the Cities of Alexandria, Fairfax, Falls Church, Manassas and Manassas Park, and the Towns of Clifton,
Dumfries, Hamilton, Haymarket, Herndon, Hillsboro, Leesburg, Lovettsville, Middleburg, Occoquan, Purcellville, Quantico,
Round Hill and Vienna, and on Interstate 95 in the counties of Stafford, Spotsylvania and Caroline, the permittee may request
VDOT regional utility marking at: http://www.vdotutilitymarking.virginia.gov
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Failure to carry out this requirement may result in permit revocation.
10) The permittee shall to notify “Miss Utility” (or each operator of an underground utility where no notification center exists) of
any planned excavation within state maintained right-of-way. This notification must be provided at least 48 hours (excluding
weekends and holidays) in advance of commencing with any planned excavation within state maintained right-of-way. Failure
to carry out this requirement may result in permit revocation.
11) Any permit may be revoked or suspended when in the opinion of the district administrator’s designee, the safety, use or maintenance
of the highway so requires.
12) The permittee shall at all times give strict attention to the safety and rights of the traveling public, their employees and
themselves. VDOT reserves the right to stop work at any time due to safety problems and/or non-compliance with the terms of
the permit. The Department may, at its discretion, complete any of the work covered in the permit or restore the right-of-way
to the department’s standards and invoice the permittee for the actual cost of such work. The permittee may be required to
move, alter, change or remove from state maintained right-of-way, in a satisfactory manner, any installation made under this
permit.
13) All work authorized under the auspices of a VDOT land use permit shall be subject to VDOT’s direction and be in accordance
with VDOT’s Road and Bridge Standards (current edition) and VDOT’s Road and Bridge Specifications (current edition).
14) Design changes, specified material changes and/or field changes from the approved plans shall be submitted to the appropriate
district administrator’s designee for review and approval prior to proceeding with the proposed changes. This submittal shall
include written justification, supplemental documentation and/or engineering calculations that support the requested changes.
15) The permittee shall meet or exceed the existing pavement design and typical section when constructing pavement widening
adjacent to an existing state maintained roadway. The proposed pavement design and typical section shall be approved by the
district administrator’s designee prior to commencing with any work within state maintained right-of-way. All pavement
widening shall be in accordance with VDOT’s Road and Bridge Standard 303.02.
16) Within the limits of a VDOT construction project it is the responsibility of the permit applicant to obtain the contractor's consent
in writing prior to permit issuance. Information regarding current and/or planned VDOT construction and maintenance
activities can be obtained at: http://www.virginiaroads.org/
.
Insurance Requirements (excluding County, Town or City)
The permittee or their agent shall secure and maintain insurance to protect against liability for personal injury and property damage
that may arise from the activities performed under the authority of a land use permit and from the operation of the permitted
activity up to one million dollars ($ 1,000,000) each occurrence to protect the Board members and the Department's agents or
employees; seventy-five thousand dollars ($75,000) each occurrence to protect the Board, the Department, or the Commonwealth
in event of suit. Insurance must be obtained prior to start of the permitted work and shall remain valid through the permit
completion date. VDOT staff may require a valid certificate or letter of insurance from the issuing insurance agent or agency prior to
issuing the land use permit.
Traffic Control and Safety
1) The permittee shall at all times give strict attention to the safety and rights of the traveling public, their employees, and
contractors. Any permit may be revoked or suspended when in the opinion of the district administrator’s designee, the safety,
use or maintenance of the highway so requires.
2) In accordance with the Virginia Department of Transportation (VDOT) Road and Bridge Specification, Special Provision 105.14,
all activities performed under the auspices of a VDOT Land Use Permit involving the installation, maintenance and removal of
work zone traffic control devices must have an individual on-site who, at a minimum, is accredited by VDOT in Basic Work Zone
Traffic Control. The accredited person must have their VDOT Work Zone Traffic Control accreditation card in their possession
while on-site.
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3) The individual accredited in Basic Work Zone Traffic Control is responsible for the placement, maintenance and removal of work
zone traffic control devices within the project limits in compliance with the permit requirements and conditions, the approved
plans and specifications, the Virginia Work Area Protection Manual, and the Manual of Uniform Traffic Control Devices.
4) A person accredited by VDOT in Intermediate Work Zone Traffic Control must be on-site to provide supervision for adjustment
to the approved layout of any standard Typical Traffic Control (TTC) layouts outlined in the Virginia Work Area Protection
Manual.
5) All traffic control plans shall be prepared by a person verified by VDOT in Advanced Work Zone Traffic Control.
6) Individuals responsible for implementation of work zone traffic control measures shall pro
vide evidence of their
accreditation upo
n request from VDOT personnel.
7) The permittee shall be
exempt from the requirements of Virginia Department of Transportation (VDOT) Road and
Bridge Specification, Special Provision 105.14 if the
authorized activity is not within the roadway (as defined in
24VAC30-151) of a state maintained highway.
8) Non-compliance with the requirements outlined in VDOT R
oad and Bridge Specification, Special Provision 105.14
may result in a stop work order and / or permit revocation.
9) All activities that require the disruption (stoppage) of traffic shall utilize VDOT certified flaggers. Flag persons shall be provided
in sufficient number and locations as necessary for control and protection of vehicular and pedestrian traffic in accordance with
the Virginia Work Area Protection Manual. All flaggers must have their certification card in their possession when performing
flagging operations within state maintained right-of-way. Any flag person found not in possession of his/her certification card
shall be removed from the flagging site and the district administrator’s designee will suspend all permitted activities.
10) Any VDOT certified flag person found to be performing their duties improperly shall have their certification revoked.
11) All signs shall be in accordance with the current edition of the Manual of Uniform Traffic Control Devices (MUTCD).
12) The permittee shall immediately correct any situation that may arise as a result of these activities that the district
administrator’s designee deems hazardous to the traveling public.
13) During authorized activities, the permittee shall furnish all necessary signs, flag persons and other devices to provide for the
protection of traffic and workers in accordance with the Virginia Work Area Protection Manual or as directed by the district
administrator’s designee.
14) Traffic shall not be blocked or detoured without permission, documented in writing or electronic communication, being granted
by the district administrator’s designee.
15) If directed by the district, requests for the implementation of temporary lane closures must be entered into the VDOT Lane
Closure Advisory Management System (LCAMS) and VaTraffic a minimum of one (1) week prior to the planned execution of lane
closure activities on state maintained highways. The permittee or their contractor(s) may enter their requests directly or
provide written requests to the VDOT Regional Operations Center as follows:
• Lane closure requests in all the counties listed below are within the Northern Region and shall be sent to:
nrolaneclosurerequests@vdot.virginia.gov
.
Counties: Arlington, Fairfax, Loudoun, Prince William, Spotsylvania, and Stafford
• Lane closure requests in all the counties listed below are within the Northwest Region and shall be sent to:
StauntonTrafficManagementCenter@vdot.virginia.gov
.
Counties: Albemarle, Alleghany, Augusta, Bath, Clarke, Culpeper, Fauquier, Fluvanna, Frederick, Greene, Highland,
Louisa, Madison, Orange Page, Rappahannock, Rockbridge, Rockingham, Shenandoah and Warren
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• Lane closure requests in all the counties listed below are within the Southwest Region and shall be sent to:
SalemSmartTrafficCenter@VDOT.Virginia.gov
.
Counties: Amherst, Appomattox, Bedford, Bland, Botetourt, Buchanan, Buckingham, Campbell, Carroll, Charlotte, Craig,
Cumberland, Dickenson, Floyd, Franklin, Giles, Grayson, Halifax, Henry, Lee, Montgomery, Nelson, Patrick, Pittsylvania
Prince Edward, Pulaski, Roanoke, Russell, Scott, Smyth, Tazewell, Washington, Wise, and Wythe.
• Lane closure requests in all the counties listed below are within the Eastern Region and shall be sent to:
HamptonRoadsTOCControllers@VDOT.Virginia.gov
.
Counties: Accomack, Greensville, Isle of Wight, James City, Northampton, Southampton, Surry, Sussex and York
• Lane closure requests in all the counties listed below are within the Central Region and shall be sent to:
RichmondDist.SmartTraffic@vdot.virginia.gov
Counties: Amelia, Brunswick, Caroline, Charles City, Chesterfield, Dinwiddie, Essex, Gloucester, Goochland, Hanover,
Henrico, King and Queen, King George, King William, Lancaster, Lunenburg, Mathews, Mecklenburg, Middlesex, New
Kent, Northumberland, Nottoway, Powhatan, Prince George, Richmond, and Westmoreland
Written requests for implementation of temporary lane closures must be submitted to the appropriate VDOT Regional
Operations Center by close of business on the preceding Wednesday for the upcoming week’s planned lane closures. All
requests being directly input into LCAMS and VaTraffic must be entered no later than 2:00 pm on the preceding Thursday
for the upcoming week’s lane closure activities. Any conflicts with other roadway work must be resolved by close of
business on Thursday the week prior to the scheduled lane closure activities with documented resolution sent to the VDOT
point of contact provided by the regional traffic operation center LCAMS Administrator. Any requests received after these
time limitations will not be approved and the proposed work within VDOT right of way requiring lane closures must be
rescheduled.
Lane closure requestors wanting direct access to LCAMS and VaTraffic must complete ITD-35E & ITD-36E
forms and return
to Ms. Carlene McWhirt at Carlene.McWhirt@VDOT.Virginia.gov. Online training is available for LCAMS and VaTraffic and
VDOT can accommodate any additional training needs. Please contact Ms. McWhirt at (571) 350-2078 to schedule training.
Authorized Hours and Days of Work
Normal hours for work under the authority of a VDOT land use permit are from 9:00 a.m. to 3:30 p.m. for all highways classified as
arterial or collector. All highways classified as local roads will have unrestricted work hours and days.
The district administrator's designee may establish alternate time restrictions in normal working hours for single use permits.
The central office permit manager may establish alternate time restrictions in normal working hours for district-wide permits.
The classifications for all state maintained highways can be found at the following link:
http://www.virginiadot.org/projects/fxn_class/maps.asp
Emergency Repair
In the event of an emergency situation that requires immediate action to protect persons or property, work may proceed within the
right-of-way without authorization from the district administrator’s designee; however, the utility owner must contact the VDOT
Emergency Operations Center as soon as reasonably possible but no later than 48 hours after the end of the emergency situation.
The utility owner must apply for a separate land use permit from the local district permit office for any emergency work performed
on state maintained right-of-way when the following actions are proposed:
• Stopping or impeding highway travel in excess of 15 minutes, or,
• Accessing facilities within limited access right-of-way, or,
• Cutting the highway pavement or shoulders.
The district administrator’s designee shall determine the applicable permit fee for emergency repair permits.
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Holiday Restrictions
Permitted non-emergency work will not be allowed on arterial and collector highway classifications from noon on the preceding
weekday through the following state observed holidays: New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving
Day, and Christmas Day. If the observed holiday falls on a Monday, the permit will not be valid from noon on the preceding Friday
through noon on Tuesday.
Excavation
All excavation within state maintained rights-of-way shall comply with OSHA Technical Manual, Chapter 2, Title Excavation: Hazard
Recognition in Trenching and Shoring. A professional engineer shall certify all shoring and/or trench boxes.
No excavated material is to be placed or tracked on the pavement without written permission from the District Administrator’s
designee. When so authorized, the pavement shall be satisfactorily cleaned by a VDOT approved method. No cleated (track-
mounted) equipment is to be used on the pavement without properly protecting the pavement from damage.
Inspection and Restoration
1) Inspection and testing of all backfill and pavement sections shall be performed in accordance with all applicable sections of
VDOT’s Road and Bridge Specifications (current edition).
2) If during or before construction it is deemed necessary for the local district permit office to assign an inspector to the project,
the permittee shall pay the Department an additional inspection fee in an amount that will cover the salary, expense allowance,
and mileage allowance for the inspection(s) assigned by the Department for handling work covered by this permit. Said
inspection fee shall be paid promptly each month on invoices rendered by the Department.
3) It shall be the decision of the district administrator’s designee whether to assign an inspector to monitor the placement of all
backfill and pavement restoration activities.
4) The absence of a VDOT inspector does not in any way relieve the permittee of their responsibility to perform the work in
accordance with the approved plans, provisions of the attached permit, VDOT’s Road and Bridge Standards (current edition) and
VDOT’s Road and Bridge Specifications (current edition).
5) The permittee shall be responsible for any settlement of all backfill or pavement restoration necessitated by authorized
excavation activities for a period of two (2) years after the completion date of permit, and for the continuing maintenance of
the facilities placed within the highway right-of-way. A one (1) year restoration warranty period may be considered, provided
the permittee adheres to the following criteria:
• The permittee retains the services of a professional engineer (or certified technician under the direction of the professional
engineer) to observe the placement of all backfill and pavement restoration.
• The professional engineer (or certified technician under the direction of the professional engineer) performs any required
inspection and testing in accordance with all applicable sections of VDOT's Road and Bridge Specifications.
• The professional engineer submits all testing reports for review and approval, and provides written certification that all
restoration procedures have been completed in accordance with all applicable sections of VDOT's Road and Bridge
Specifications prior to completion of the work authorized by the permit.
6) Whenever existing pavement is permitted to be cut, not over one-half of the roadway width shall be disturbed at one time and
the first open cut trench section shall be satisfactorily restored to allow for the passage of traffic prior to the second half of the
roadway surface can be disturbed.
7) All crossing of existing pavement shall be bored, pushed or jacked an appropriate distance from the edge-of-pavement so as not
to impede the normal flow of traffic or damage the existing pavement section. Existing pavement shall not be cut unless
approved by the district administrator’s designee and then only if justifiable circumstances prevail or proof is shown that a
thorough attempt has been made to push, bore or jack.
8) Authorized daily trench excavation within pavement sections shall not exceed 500 feet in length.
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9) Pavement restoration shall be in accordance with the attached VDOT LUP-OC Pavement Open Cut Special Provisions.
10) Where the pavement is disturbed or deemed weakened in its entirety or such portions as deemed desirable by the Department,
the pavement shall be restored or replaced in a manner that is satisfactory to the district administrator’s designee.
Environmental
1) In accordance with the Virginia Department of Transportation (VDOT) Road and Bridge Specification §107.16, all contractors
performing regulated land disturbing activities within VDOT right-of-way must have at least one (1) employee that has
successfully completed the VDOT Erosion & Sediment Control Contractor Certification training. This person shall be on site
during all land disturbance activities and will be responsible for insuring compliance with all applicable local, state and federal
erosion and sediment control regulations during land disturbance activities. This person must have their certification card with
them while on the project site. The land use permit will be suspended if proof of certification cannot be provided. Regulated
land disturbing activities are defined as those activities that disturb 2,500 square feet or greater in Tidewater, Virginia or 10,000
square feet or greater in all other areas of the State. The Department will require evidence of this certification with any land
use permit application that involves utility and/or commercial right of way improvement. Improper installation, maintenance
and removal of erosion and sediment control devices may result in revocation of VDOT Erosion & Sediment Control Contractor
Certification.
2) The permittee is responsible for pursuing and obtaining any and all environmental permits which may be required to pursue the
proposed activity prior to any work beginning within state maintained right-of-way.
3) In the event hazardous materials or underground storage tanks are encountered within state maintained right-of-way during
authorized activities, the permittee shall suspend all work immediately then notify the local district permit office and other
responsible parties, i.e., the local fire department, emergency services, Department of Environmental Quality, etc. The
permittee is responsible for coordination and completion of all required remediation necessary to complete the permitted
activities within the state maintained right-of-way. The permittee shall provide evidence of such compliance to the local district
permit office prior to recommencement of permitted activities.
4) In the event cultural resources, archaeological, paleontological, and/or rare minerals are encountered within the right of way
during authorized activities, the permittee shall suspend all work immediately then notify the local district permit office and the
proper state authority charged with the responsibility for investigation and evaluation of such finds. The permittee will meet all
necessary requirements for resolving any conflicts prior to continuing with the proposed activities within the state maintained
right-of-way, and shall provide evidence of such compliance to the local district permit office.
5) Roadway drainage shall not be blocked or diverted. The shoulders, ditches, roadside, drainage facilities and pavement shall be
kept in an operable condition satisfactory to the Department. Necessary precautions shall be taken by the permittee to insure
against siltation of adjacent properties, streams, etc., in accordance with VDOT's current standards or as prescribed by the
Department’s Environmental Manual and the district administrator’s designee.
Entrances
1. Plans for the proposed installation of entrance(s) to state maintained highway right-of-way shall be designed in accordance
with the current edition of VDOT’s Road and Bridge Standards, VDOT’s Road and Bridge Specifications and per VDOT Road
Design Manual, Appendix F located at
http://www.extranet.vdot.state.va.us/locdes/Electronic_Pubs/2005%20RDM/AppendF.pdf.
2. VDOT's authority to regulate highway entrances is provided in §, §33.2-240, and §33.2-241
of the Code of Virginia and its
authority to make regulations concerning the use of highways generally is provided in §33.2-210 of the Code of Virginia.
Regulations regarding entrances are set forth in VDOT's regulations promulgated pursuant to §33.2-245 of the Code of
Virginia.
3. The permittee shall be responsible for the design and installation of a private entrance under the auspices of a VDOT land
use permit however the permittee may request that VDOT forces install the private entrance at the permittee’s expense.
4. Street connections, private entrances, and construction entrances shall be kept in satisfactory condition during all activities
authorized under the auspices of a VDOT land use permit. Entrances shall not be blocked. Ample provisions must be made
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to provide safe ingress and egress to adjacent properties at all times. Entrances that are disturbed shall be restored to the
satisfaction of the property owner and the district administrator’s designee.
Utilities
1) Prior to any excavation, the permittee shall comply with the terms of Title 56, Chapter 10.3
of the Underground Utility Damage
Prevention Act and §56-265.14 through §56-265.20 of the Code of Virginia. This permit does not grant permission to grade on
or near property of others, or, adjust or disturb in anyway existing utility poles or underground facilities within the permitted
area. Permission to do so must be obtained from the impacted utility company and any expense involved shall be borne by the
permittee. Any conflicts with existing utility facilities must be resolved between the permittee and the utility owner(s) involved.
2) All underground utility installations within limited access right-of-way shall have a minimum of 36 inches of cover. All
underground utilities within non-limited access right-of-way will require a minimum of 36 inches of cover, except underground
cables that provide telecommunications service shall be at a minimum of 30 inches of cover.
3) Where feasible, all aboveground installations (such as fire hydrants, telephone pedestals, markers, etc.) shall be located
adjacent to the outside edge of the right-of-way line and in accordance with minimum clear zone requirements. All manhole
covers, valve box, etc., shall be installed two inches below existing ground line and shall conform to existing contours.
4) No poles, guys, anchors, etc., are to be placed on state maintained right-of-way unless authorized under the auspices of a VDOT
land use permit. At no time will any such facilities be allowed between the ditch line and the traveled roadway.
5) All overhead installations crossing non-limited access highways shall provide a minimum of 18 feet of vertical clearance or at a
minimum height as established by the National Electric Safety Code, whichever is greater. All overhead utility installations
within limited access right-of-way shall maintain a minimum of 21 feet of vertical clearance. The vertical clearance for all new
overhead parallel installations within non-limited access rights-of-way shall be in compliance with standards as specified in the
National Electric Safety Code.
Final Inspection and Completion of Permit
Upon completion of the work covered by this permit all disturbed areas outside of the roadway prism shall be restored to
their original condition as found prior to starting such work.
Completion of this permit is contingent upon the permittee’s completion of the authorized work in accordance with the
approved plan and compliance with all governing bodies involved in the total completion of work on state maintained right-of-way.
Upon completion of the work under permit, the permittee shall provide notification, documented in writing or electronic
communication, to the district administrator's designee requesting final inspection. This request shall include the permit
number, county name, route number and name of the party or parties to whom the permit was issued.
The district administrator's designee shall promptly schedule an inspection of the work covered under the permit and advise the
permittee of any necessary corrections.
Permit Revocation
At the discretion of the district administrator’s designee, a land use permit may be revoked upon written finding that the permittee
was not in compliance with all requirements contained herein and/or violated the terms of the permit, or any state and local laws
and ordinances regulating activities within the right-of-way.
The district administrator's designee shall promptly schedule an inspection of the work covered under the permit and advise the
permittee of any necessary corrections
Permittee Notice
The preceding provisions are intentionally condensed in format and should not be loosely interpreted by the permittee without
consultation with the central office permit manager and affirmation from the Land Use Permit Regulations.
11
VIRGINIA WORK ZONE TRAFFIC CONTROL TRAINING OPTIONS
The following three options are available to receive Work Zone Traffic Control (WZTC) training based on an individual’s job duties
and responsibilities as required by the FHWA Final Rule on Work Zone Safety and Mobility and the Virginia Department of
Transportation:
OPTION 1 – Have someone trained to become a qualified instructor in your company who can then instruct others , utilizing training
material provided by VDOT. The following qualifications must be met in order to teach the VDOT Basic, Intermediate, or Advanced
WZTC training courses:
• Basic – Be flagger certified either by VDOT or by the American Traffic Safety Services Association (ATSSA); possess two years of
practical experience in Highway Design, Construction, Maintenance, or Traffic Operations; possess two years of documented
experience in conducting training courses; and successfully complete the VDOT WZTC Intermediate or Advanced course or
complete the ATSSA Virginia Intermediate/Traffic Control Supervisor (TCS) course.
• Intermediate - Be flagger certified either by VDOT or by ATSSA; possess two years of practical experience in Highway Design,
Construction, Maintenance, or Traffic Operations; possess two years of documented experience in conducting training courses;
complete and possess the ATSSA Virginia Intermediate/TCS certification.
• Advanced - Be flagger certified either by VDOT or by ATSSA; possess two years of practical experience in Highway Design,
Construction, Maintenance, or Traffic Operations; possess two years of documented experience in conducting training courses;
complete and possess the ATSSA Virginia Advanced Traffic Control Design Specialist (TCDS) certification or ATSSA Virginia
Intermediate TCS certification.
To become an approved instructor, an application must be completed listing the above qualifications and sent to the chairman of
VDOT’s WZST committee at the following location:
http://www.virginiadot.org/business/resources/wztc/wztc_inst_app_form.pdf
Once a person has become an approved instructor, training material can be obtained from VDOT using the order form obtained
from the following location (requires an approved instructor identification number):
http://www.virginiadot.org/business/resources/wztc/WZTC_order_form.pdf
OPTION 2 – Obtain the services of an approved instructor from VDOT’s Approved WZTC Instructor List to teach the course or courses you
need for your employees.
The Approved WZTC Instructor’s List can be obtained at the following location:
http://www.virginiadot.org/business/resources/wztc/Approved_WZTC_Instructors.pdf
A list of Approved Providers of training can be obtained at the following location:
http://www.virginiadot.org/business/resources/wztc/wztc_training_sponsors.pdf
OPTION 3 – Send personnel to classes conducted by approved sources such as ATSSA Virginia or the Virginia Local Technical
Assistance Program (LTAP).
Courses by ATSSA Virginia can be found at the following location:
http://atssa.com/cs/course_information/courses_by_state?state=56
Courses by the Virginia LTAP can be found at the following location:
http://ltap.cts.virginia.edu/2%20Page%20Calendar%20June%20-%20Sept%2009.pdf
Basic WZTC courses by the Virginia Rural Water Association can be found at the following location:
http://www.vrwa.org/
(See Training Schedule)
Training by the Virginia Transportation Construction Alliance (VTCA) can be found at the following location: http://vtca.org/
Visit the following site for additional information regarding Virginia’s Work Zone Traffic Control training program:
http://www.virginiadot.org/business/trafficeng-WZS.asp
12
LAND USE PERMIT
LUP-OC
Open-Cut Pavement Restoration Requirements
Any of the following provisions that may apply, shall apply:
1. The permittee shall be responsible for the restoration of pavement on state maintained highways in accordance with all
applicable sections of the VDOT Road and Bridge Specifications, VDOT Road and Bridge Standards and this document.
2. Whenever existing pavement is permitted to be cut, not over one-half of the roadway width shall be disturbed at one time
and the first open cut trench section shall be satisfactorily restored to allow for the passage of traffic prior to the second
half of the roadway surface can be disturbed.
3. All trench backfill material shall be Select Material Type I having a minimum CBR of 30 and free from any wood, decaying
material, asphalt, concrete, ice, frost, large clods, stone or debris.
4. Trench backfill material shall be compacted to a minimum of 95% of the theoretical maximum density at optimum moisture
content, as determine by VDOT testing procedures (VTM1), using mechanical tamping throughout the depth of the trench
in 6-inch lifts to ensure that the adequate support is provided for the aggregate sub-base layer is adequately supported.
5. For roadways with a bituminous concrete asphalt pavement section the compacted trench backfill shall be capped with 10
inches (10”) of Type I, Size 21-A or 21-B aggregate compacted to 100% of the theoretical maximum density at optimum
moisture content covering the entire trench width and a minimum six inch (6”) bench on each side of the excavated trench
or as determined by the district administrator’s designee.
6. A bituminous concrete asphalt base course (BM-25) having a minimum thickness of six inches (6”), or matching the existing
base course thickness, shall be placed over the benched aggregate sub-base to the bottom elevation of the existing asphalt
concrete surface course.
7. All sides of the excavated trench shall be saw-cut trimmed to neat straight lines and a tack coat of RC-250 liquid asphalt
applied at a rate of 0.1 gallon per square yard (or as determined by the district administrator’s designee) prior to placing
the bituminous concrete asphalt base course (BM-25.0) and/or replacement of the bituminous concrete asphalt surface
course (SM-9.5A or SM-9.5D).
8. The existing pavement surface course adjacent to the excavated trench shall be milled and repaved with bituminous
concrete asphalt (SM-9.5A or SM-9.5D) having of a minimum thickness of 1-1/2 inches (1.5”). This operation shall cover the
entire trench width and extend 12 inches (12”) beyond the edge of the trench on longitudinal open cuts and 25 feet (25’)
beyond the trench centerline on perpendicular open cuts, or as determined by the district administrator’s designee.
9. Open cuts in surface treated roadway sections with an aggregate base course shall be replaced with the same layer(s) as
roadway sections with a bituminous concrete asphalt pavement structure except the sub-base layer (Type I, Size 21-A or 21-
B) may be reduced to six inches (6”) and the bituminous concrete asphalt base layer (BM-25.0) may be reduced to four
inches (4”) while maintaining the required six inch (6”) bench on both sides of the excavated trench. The surface course
restoration material and thickness shall match the existing surface.
10. Replacement of all bituminous concrete asphalt and surface treated courses shall be rolled with equipment having a
manufacturer’s rating of ten (10) tons until the aggregate is keyed into the bitumen. Where rolling is not possible, a
mechanical tamper shall be utilized.
11. Full depth aggregate stone may be placed in the trench daily up to maximum length of 500 feet, at which time either
temporary or permanent pavement restoration procedures must be implemented.
13
12. Should the application of the bituminous concrete asphalt surface course be delayed due to adverse weather conditions,
the contra
ctor shall provide and maintain a temporary pavement section that is acceptable to the district administrator’s
designee until such time as the appropriate permanent pavement restoration can be achieved.
13. The permittee shall be responsible for any settlement in the backfill or pavement for a period of two (2) years after the
completion date of permit and for the continuing maintenance of the facilities placed within the highway right-of-way.
14. A one-year restoration warranty period may be considered, provided the permittee adheres to the following criteria:
• The permittee retains the services of a professional engineer (or certified technician under the direction of the professional
engineer) to observe the placement of all fill embankments, pavement, and storm sewer and utility trench backfill.
• The professional engineer (or certified technician under the direction of the professional engineer) performs any
required inspection and testing in accordance with all applicable sections of VDOT's Road and Bridge Specifications.
• The professional engineer submits all testing reports for review and approval, and provides written certification that all
restoration procedures have been completed in accordance with all applicable sections of VDOT's Road and Bridge
Specifications prior to completion of the work authorized by the permit.
15. The district administrator’s designee may request and review the backfill compaction test results and/or authorize an
inspector to monitor the trench backfill and compaction operations.
16. The use of steel plates to provide a temporary riding surface will not be allowed between November 1 and April 1. The use
of steel plates between April 2 and October 31 shall be in accordance with VDOT standards and specifications.
17. Traffic shall be maintained at all times in accordance with the Virginia Work Area Protection Manual and a VDOT approved
Maintenance of Traffic (MOT) plan.
18. The permittee shall notify the district administrator’s designee a minimum of 72 hours prior to initiating any pavement
open cutting operations.
19. The trench to be backfilled shall be made as dry as practicable at the time of backfilling by pumping, bailing, draining, or
other approved dewatering method.
20. All asphalt pavement restoration activities shall be in accordance with the Asphalt Pavement Restoration Detail for Open
Cut Utility Installations contained herein.
14
LAND USE PERMIT
LUP-OC
Open-Cut Pavement Restoration Requirements
Asphalt Pavement Restoration Detail for Open Cut Utility Installations
6” Bench
Min.
10” min.
6” Bench
Min.
Saw-cut existing pavement
to the full depth of asphalt
6” min.
1.5” min.
7.5” total asphalt
concrete pavement
depth or equal to
the depth of existing
asphalt concrete,
whichever is greater
NOTES:
* Asphalt Concrete Surface Material:
SM-9.5A for ADT < 10,000
SM-9.5D for ADT > 10,000
The district administrator’s designee shall determine the
restoration requirements for other pavement types.
** Trench width and pipe bedding shall be in
accordance with VDOT Std. PB-1
*** 12 inches minimum beyond the edge of the trench
on longitudinal open cuts, or 25 feet minimum beyond
the trench centerline on perpendicular open cuts, or as
determined by the district administrator’s designee.
Date: August 27, 2014
Aggregate Base Material, Type I
Size No. 21A or 21B
12” min.
12” min.
Sub-base course depth
shall be 10” or equal to
depth of existing sub-base,
whichever is greater
Asphalt Concrete Surface Material
*
Asphalt Concrete Base, Type BM-25.0A
**
Class I backfill material in accordance
with Section 302 of the Road and Bridge
Specifications
No. 26 or 27 aggregate pipe bedding in
accordance with Sections 205 & 302 of
the Road and Bridge Specifications
Select Material Type I with minimum CBR = 30
Horizontal and vertical surfaces
shall be tacked with RC-250 liquid
asphalt at a rate of 0.1 gallon per
SY, or as determined by the
district administrator’s designee
LAND USE PERMIT
LUP-LC
Bank Irrevocable Letter of Credit
[Bank Letterhead]
LETTER OF CREDIT BANK AGREEMENT
Date: _____________________________________________ APPLICANT NAME: _____________________________________
Issuing Bank: ______________________________________ Tax ID number or Driver’s license Number: _________________
Address: __________________________________________ Telephone Number: ____________________________________
City: __________________ State______ Zip Code________ Address: ______________________________________________
Amount: __________________________________________ City: ____________________ State _______ Zip Code _________
Expiration Date: ___________________________________
VIRGINIA DEPARTMENT OF TRANSPORTATION
Address: ___________________________________________________
City: _______________________ State ______ Zip Code ___________
We hereby issue Irrevocable Letter of Credit number ________________________ in favor of the Virginia Department of
Transportation (the Department) for the account of ___________________________________________________ in an amount not
to exceed ________________________________________________U.S. Dollars ($___________________ ) available by sight draft
on the above stated issuing bank accompanied by the documents specified below:
A certified statement signed by the Department’s Permit Manager or their representative stating that___________________ has not
satisfactorily completed work pursuant to the permit issued to the permittee or his agent to perform the work as described on the
face of the land use permit in the County of _________________________________________, Virginia.
A certified statement signed by the Department’s Permit Manager or their representative stating that: “This draw is for the explicit
purpose of providing for completion or restoration of the right of way to the terms of the Land Use Permit Regulations and
pursuant to the agreement of the permittee or their Agent to perform the work covered by permit to the satisfaction of the
Department.” All drafts must bear the clause “Drawn under _____________________________ Irrevocable Letter of Credit No.
________________ dated ________________________________________________ , 20________.” We hereby engage with
drawers, endorsers and bona fide holders that all drafts drawn in compliance with the terms of this credit shall be duly honored
upon presentation and delivery of this document. This Irrevocable Letter of Credit shall remain in full force and effect for a period of
two (2) years from the date hereof and shall automatically renew itself from year to year for three (3) years, one (1) year periods
thereafter unless and until the above issuing bank shall give ninety (90) days prior written notice to the department by CERTIFIED
MAIL, RETURN RECEIPT REQUESTED, of its intent to terminate same at the expiration of said ninety-day period. During said ninety
(90) days notice period, this Irrevocable Letter of Credit shall remain in full force and effect.
During the last thirty (30) days while this Irrevocable Letter of Credit is in force and effect after notice of termination has been given,
the Department may draw up to the full amount of this Irrevocable Letter of Credit when accompanied by a document stating that
______________________________ has failed to provide an acceptable substitute Irrevocable Letter of Credit or deposit in an
escrow account, and further stating that “The draw will be held by the Department for the sole purpose of providing for the
completion or restoration of the right of way for work covered by the land use permit issued to ____________________________
until such work is completed or restored to the Department’s satisfaction. This Irrevocable Letter of Credit shall be terminated
upon the Department’s Permit Manager or their appointed representative giving written release stating that the terms of the
permit have been completed and accepted by the Department.” Requests for the termination of this Irrevocable Letter of Credit
should be addressed to the local Department office that issued the land use permit.
Except as otherwise expressly stated herein, this credit is subject to the Uniforms Customs & Practices for Documentary Credit (2007
Revision), International Chambers of Commerce Publication No. 600.
Attest: ____________________________________
____________________________________
(Seal)
________________________________________
Authorized Signature
__________________________________________________
Type or Print Name
__________________________________________________
Title
Surety Bond LUP-SB
BE KNOWN THAT WE as Principal,
and__________________________________________________________________, a corporation duly incorporated under the Laws of the State of
_____________________________________________, as Surety, are held and firmly bound unto the Commonwealth of Virginia in the full and just sum
of ___________________________________________ U.S. Dollars ($ ______________________ ), to be paid to the Commonwealth of Virginia to the
payment whereof we hereby bind ourselves and our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents,
sealed and dated this ______ day of ____________________ (month), 20_______ (year).
WHEREAS, The said Principal hereunder has been or will be granted permit(s) authorizing one or more of the following activities;(A) to move house
property upon public highways of Virginia (B) to cut surface of the highways of Virginia, or to tunnel under such highways; (C) to install and/or erect and
maintain telephone, electric power lines, water, sewer, gas or other utilities on, under or over such highways, bridges or tunnels;(D) to install an entrance or
tie-in into a public roadway and/or grading upon the Right -of- way; or (E) for the following purposes: Explain below exact purpose(s) for which surety
coverage is being obtained.
___________________________________________________________________________________________________________________________
_________________________________________________________________________________________________
Work to be performed in the county, city or town of:_____________________________________________
THEREFORE, The conditions of this obligation are such that if the said Principal shall in all respects comply with the terms and conditions of said
permit(s), and fully meet and perform obligations thereunder in accordance with requirements for permits as set forth in the Land Use Permit Manual in
effect at time of permit issuance, and shall satisfactorily complete the work permitted, and shall indemnify and save harmless the Commonwealth of
Virginia against and from all loss, cost, expense damage or injury to highways and bridges and to persons and property lawfully on such highways, growing
out of the granting of such permit(s) to said Principal, then this obligation be void, otherwise to be and remain in full force and virtue.
NOW, THEREFORE, It is expressly understood that this Bond may be canceled by the Surety at the expiration of sixty (60) days from the date which the
Surety shall have lodged with the Commonwealth Transportation Commissioner or his designees written notice to so cancel. This provision, however, shall
not operate to relieve, release or discharge the Surety from any liability already accrued, or which shall accrue, on permits issued before the expiration of the
sixty-day period. Bonds securing performance on specified active permit(s) may be canceled only upon satisfactory completion of permit(s), as
determined by the Department Engineer. NOTE: Continuous Bond cannot be canceled unless facilities covered by the permit have been removed from
the Right -of-way, or the principal has arranged for replacement surety protection. ALL permit work covered under section (C) above shall be covered
by a bond at all times.
Said principal and surety, being properly authorized, have caused these presents to be executed and their seals affixed the day and year first above written.
Surety name_____________________________________ Principal name____________________________________
Bond number ____________________________________ TAX ID # or DMV ID #____________________________
Address_________________________________________ Address ________________________________________
City ________________ State _____ ZIP ___________ City ____________________ State _______ ZIP ________
Contact person ___________________________________ Contact person____________________________________
Phone number ___________________________________ Phone number ___________________________
Attorney-in-Fact Name____________________________ Signature ________________________________________
Signature_______________________________________
Attorney-In-Fact POWER OF ATTORNEY AUTHORIZATION TO BE ATTACHED
(Seal)
Acknowledgement of Principal
STATE OF _______________________________ COUNTY / TOWN / CITY OF ____________________________________________
I, the undersigned, a Notary Public in and for the County / Town / City aforesaid, in the State aforesaid, do certify that,
______________________________________________________________________whose name as Principal is signed to the foregoing writing bearing date this______ day of
__________________ (month), 20_____ (year), personally appeared before me and acknowledged the same.
Given under my hand this day of _________________ (month), 20____ (year) My Commission expires: ____________________
______________________________________________________________
Notary Public
Affidavit and Acknowledgement of Surety
STATE OF _____________________________ COUNTY/TOWN/CITY OF ______________________
I, the undersigned, a Notary Public in and for the County/Town/City aforesaid, in the State aforesaid do certify that, .
(Name of Attorney in Fact) personally appeared before me and made oath that he is . (Title) of the
(Name of Surety), that he is duly authorized to execute the foregoing bond by virtue of a certain power of attorney of said company; that said power of attorney has not been revoked;
that the said company has complied with all the requirements of law regulating the admission of such companies to transact business in the State of Virginia; that the said company
holds the certificate of the Commissioner of Insurance authorizing it to do business in the State of Virginia; that it has a paid-up cash capital of not less than $250,000; that the paid-
up capital plus the surplus and undivided profits of said company is $ ; that the penalty of the foregoing bond is not in excess of ten percentum of said sum; that
the said company is not by said bond incurring in the aggregate, on behalf or on account of the principal names in said bond, a liability for an amount lager than one-tenth of its paid-
up capital, plus its surplus and undivided profits; that the said company is solvent and fully able to meet promptly all its obligations, and the said (Attorney
in fact name) thereupon, in the name and on behalf of the said company, acknowledged the foregoing writing as its act and deed.
Given under my hand this ________day of _________________(month), 20____ (year) My Commission expires:___________________
_____________________________________________________________
Notary Public
Original to be filed with the Virginia Department of Transportation
Request for Land Use Permit Surety Bond Cancellation may be addressed to:
Virginia Department of Transportation
_________________________________
_________________________________
LAND USE PERMIT
RESOLUTION
August 26, 2014
[County, City or Town Letterhead]
“RESOLUTION”
WHEREAS, it becomes necessary from time to time for the [County, City or Town] of [County, City or Town Name] to obtain land use
permits from the Virginia Department of Transportation to install, construct, maintain and operate certain public works and public
utilities projects along, across over and upon highway systems of the Commonwealth of Virginia; and,
WHEREAS, expense, damage or injury may be sustained by the Commonwealth of Virginia growing out of granting to the [County,
City or Town] of [County, City or Town Name by the Virginia Department of Transportation of said permits for the work aforesaid;
NOW, THEREFORE, BE IT RESOLVED by the [County, City or Town] [Board of Supervisors, City or Town Council] this [Date] day of
[Month], [Year]:
Section 1: That in accordance with the provisions of Section 24VAC30-151-720 of the Land Use Permit Regulations of the Virginia
Department of Transportation, the [County, City or Town] of [County, City or Town Name] does hereby grant assurances to the
Virginia Department of Transportation (VDOT) that it shall in all respects comply with all of the conditions of the permit or permits
that have been, or will be, granted to the [County, City or Town] of [County, City or Town Name] and that said jurisdiction does
hereby certify that it will carry liability insurance for personal injury and property damage that may arise from the work performed
under permit and/or from the operation of the permitted activity as follows: up to one-million dollars ($1,000,000) each occurrence
to protect the Commonwealth Transportation Board members and the Virginia Department of Transportation’s agents or
employees; seventy-five thousand dollars ($75,000) each occurrence to protect the Commonwealth Transportation Board, the
Virginia Department of transportation or the Commonwealth of Virginia in the event of suit.
Section 2: That the County Administrator, City or Town Mayor, or their designee, be, and hereby is authorized to execute on behalf
of the [County, City or Town] of [County, City or Town Name] all land use permits and related documents of the Virginia Department
of Transportation.
Section 3: That this resolution shall be a continuing resolution and shall not be revoked unless and until sixty (60) days written
notice of any proposed revocation be submitted to the Virginia Department of Transportation.
Section 4: That the [County, City or Town] of [County, City or Town Name] shall, if requested by the Virginia Department of
Transportation, provide a letter that commits to using the surety provided by its contractor or to have the contractor execute a dual
obligation rider that adds the Virginia Department of Transportation as an additional obligee to the surety bond provided to the
locality, with either of these options guaranteeing the work performed within state maintained right-of-way under the terms of the
land use permit for that purpose.
BE IT STILL FURTHER RESOLVED that the County Administrator, City or Town Mayor, or their designee, be, and hereby is authorized
and directed to procure insurance required by Section 1 herein.
The foregoing Resolution was adopted by the [County Board of Supervisors, City or Town Council] at its regular meeting held on [Day,
Month, Year] in [County, City or Town Name], Virginia.
[Authorized Signature]
[Printed Name & Title]
[County, City or Town Name]
LAND USE PERMIT
LUP-CSB
Corporate Surety Bond
[Company Letterhead]
CORPORATE SURETY BOND
KNOW ALL MEN BY THESE PRESENTS THAT_________________________________ a public service corporation
duly incorporated under the laws of the Commonwealth of Virginia, is held and firmly bound unto the
Commonwealth of Virginia in the full and just sum of $__________________________________, current money of
the United States, to be paid to the said Commonwealth of Virginia, to the payment whereof
___________________________________ binds itself and its heirs, executors, administrators, and assigns, jointly
and severally, firmly by these presents, sealed and dated this _____ day of_______________ , _________.
WHEREAS, ____________________________________ has been or will be granted permits authorizing the
following activities: (a) to cut the surface of the highways of the Commonwealth, or to tunnel under such highways,
(b) to install and/or erect and maintain gas pipelines and appurtenant facilities on, under or over such highways,
bridges, or tunnels.
NOW, THERFORE, The conditions of this obligation are such that, if ________________________ shall in all
respects comply with the conditions of the permit or permits granted or to be granted and the requirements for
permits, as set forth in the “Land Use Permit Regulations” in effect at time of issuing permit, and shall indemnify
and save harmless the Commonwealth of Virginia against and from all loss, cost, expense, damage, or injury to
highways and bridges and to persons and property lawfully on such highways, growing out of the granting of such
permits to , _________________________________ then this obligation to be void, otherwise to be and remain in
full force and virtue.
This Surety Bond cannot be cancelled unless facilities covered by the permit have been removed from the right of
way, or ______________________________has arranged substitute surety protection.
IN WITNESS WHEREOF, _____________________________________ being properly authorized has caused these
presents to be executed and its seal affixed the day and year first above written.
BY: _________________________________________________
NAME: ______________________________________________
TITLE: _______________________________________________
April 1, 2017
Form
W-9
Revised March 2022
Commonwealth of Virginia
Substitute W-9 Form
Request for Taxpayer Identification
Number and Certification
Please select the appropriate Taxpayer Identification Number (EIN or SSN) type and
enter your 9 digit ID number . The EIN or SSN provided must match the name given
on the “Legal Name” line to avoid backup withholding. If you do not have a Tax ID
number, please reference "Specific Instructions‐ Section 1." If the account is in more
than one name, provide the name of the individual who is recognized with the IRS as
the responsible party.
Social Security Number (SSN)
Employer Identification Number (E
IN)
Unique Entity Identifier (UEI) (see instructions)
Legal Name:
Business Name:
Entity Type
Individual
Sole
Proprietorship
Partnership
Trust
Estate
Government
Non‐Profit
S‐Corporation
C‐Corporation
Disregarded
Entity
Partnership
Corporation
Entity Classification
Professional
Services
Political
Subdivision
Real
Estate
Agent
VA
Local
Government
Federal
Government
VA
State
Agency
Med
ical
Services
Legal
Services
Joint
Venture
Tax
Exempt
Organization
OTH
Government
Other
Exemptions (see instructions
)
Exempt payee code
(if any):
(fr
om backup withholding)
Exemption from FATCA reporting
code (if any):
Contact Information
Legal Address:
City: State : Zip Code:
Remittance Address:
City:
State
:
Zip
Code:
Name:
Email Address:
Corporation
c
tion 1‐Taxpayer Identification
Se
c
Limited Liability Company
Business Phone:
Fax Number:
Mobile Phone:
Alternate Phone:
Section 2‐ Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a)
I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or c) the IRS has notified me that I am
no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined later in general instructions), and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions: You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not
apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual
retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but
you must provide your correct TIN. See instructions titled Certification
Printed Name:
Authorized U.S. Signature:
Date:
If you are a nonresident alien or a foreign entity, give the
requester the appropriate completed Form W-8 or Form
8233.
What is backup withholding? Persons making certain
payments to you must under certain conditions withhold and
pay to the IRS a percentage of such payments. This is called
“backup withholding.” Payments that may be subject to
backup withholding include interest, tax-exempt interest,
dividends, broker and barter exchange transactions, rents,
royalties, nonemployee pay, payments made in settlement of
payment card and third party network transactions, and
certain payments from fishing boat operators. Real estate
transactions are not subject to backup withholding.
You will not be subject to backup withholding on payments
you receive if you give the requester your correct TIN, make
the proper certifications, and report all your taxable interest
and dividends on your tax return.
Payments you receive will be subject to backup
withholding if:
1. You do not furnish your TIN to the requester,
2. You do not certify your TIN when required (see Section 2
Certification for details),
3. The IRS tells the requester that you furnished an incorrect
TIN,
4. The IRS tells you that you are subject to backup withholding
because you did not report all your interest and dividends on
your tax return (for reportable interest and dividends only), or
5. You do not certify to the requester that you are not subject
to backup withholding under 4 above (for reportable interest
and dividend accounts opened after 1983 only).
Certain payees and payments are exempt from backup
withholding.
What is FATCA reporting? The Foreign Account Tax
Compliance Act (FATCA) requires a participating foreign
financial institution to report all United States account holders
that are specified United States persons. Certain payees are
exempt from FATCA reporting.
Updating Your Information
You must provide updated information to any person to whom
you claimed to be an exempt payee if you are no longer an
exempt payee and anticipate receiving reportable payments in
the future from this person. For example, you may need to
provide updated information if you are a C corporation that
elects to be an S corporation, or if you no longer are tax
exempt. In addition, you must furnish a new
Form W-9 if the name or TIN changes for the account, for
example, if the grantor of a grantor trust dies.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN to
a requester, you are subject to a penalty of $50 for each such
failure unless your failure is due to reasonable cause and not
to willful neglect.
Civil penalty for false information with respect to
withholding. If you make a false statement with no reasonable
basis that results in no backup withholding, you are subject to
a $500 penalty.
Criminal penalty for falsifying information. Willfully falsifying
certifications or affirmations may subject you to criminal
penalties including fines and/or imprisonment.
Misuse of TINs. If the requester discloses or uses TINs in
violation of federal law, the requester may be subject to civil
and criminal penalties.
Specific Instructions
Section 1 -Taxpayer Identification
Check the appropriate Tax Identification Number (TIN) type.
Enter your EIN/SSN in the space provided. If you are a
resident alien and you do not have and /or are not eligible to
get an SSN, your TIN is your IRS individual taxpayer
identification number (ITIN). Enter it in the social security
number box. If you do not have an ITIN, see How to get a TIN
below.
Number (SSN)" box and enter the SSN of the sole
proprietor.
e. If you are a Single-Member LLC that is disregarded as
an entity, check the "Social Security Number (SSN)" box
and enter the member's SSN.
Note: If an LLC has one owner, the LLC's default tax status
is "disregarded entity". If an LLC has two owners, the
LLC's default tax status is "partnership". If an LLC has
elected to be taxed as a corporation, it must file IRS Form
2553 (S Corporation) or IRS Form 8832 (C Corporation).
Vendors are requested to enter their Unique Entitiy Identifier
Number (UEI), if applicable. See number requirement below.
Unique Entity Identifier (UEI) number requirement. The
United States Office of Management and Budget (OMB)
requires all vendors that receive federal grant funds have
their UEI number recorded with and subsequently
reported to the granting agency. If your entity is
registered in SAM.gov today, your Unique Entity ID (UEI)
has already been assigned and is viewable in SAM.gov
Legal Name. If you are an individual, you must generally enter
the name shown on your social security card. However, if you
have changed your last name, for instance, due to marriage
without informing the Social Security Administration of the
name change, enter your first name, the last name shown on
your social security card, and your new last name. If the
account is in joint names, list first and then circle the name of
the person or entity whose number you enter in Part I of the
form. If you are using a name other than that which is listed
on a Social Security Card, please enter the legal entity name as
filed with the IRS. In general, enter the name shown on your
income tax return. Do not enter a Disregarded Entity Name
on this line.
Business Name. Business, Disregarded Entity, trade, or DBA
("doing business as") name.
Entity Type. Select the appropriate entity type.
Sole proprietor. Enter your individual name as shown on your
social security card on the “Legal Name” line. You may enter
your business, trade, or “doing business as (DBA)” name on
the “Business Name” line.
Partnership. A partnership is an entity reflecting a relationship
existing between two or more persons who join to carry on a
trade or business. Enter the partnerships entity's name on
the "Legal Name" line. This name should match the name
shown on the legal document creating the entity. You may
enter your business, trade, or "doing business as (DBA) name
on the "Business Name" line.
Trust. A legal entity that acts as fiduciary, agent or trustee on
behalf of a person or business entity for the purpose of
administration, management and the eventual transfer of
assets to a beneficial party. Enter the name of the legal entity
on the "Legal Name" line.
Estate. A separate legal entity created under state law solely
to transfer property from one party to another. The entity is
separated by law from both the grantor and the beneficiaries.
Enter the name of the legal entity on the "Legal Name" line.
Corporation. A company recognized by law as a single body
with its own powers and liabilities, separate from those of the
individual members. Enter the entity's name on the "Legal
Name" line and any trade or "doing business as (DBA)" name
on the "Business Name" line.
S-Corporation. A corporation that is taxed liked a partnership:
a corporation in which five or fewer people own at least half
the stock. Enter the entity's name on the "Legal Name" line
and any trade or "doing business as (DBA)" name on the
"Business Name" line.
C-Corporation. A business that is taxed as a separate entity: a
business taxed under Subchapter C of the Internal Revenue
Code and legally distinct from its owners. Enter the entity's
name on the "Legal Name" line and any trade or "doing
Corporations are exempt from backup withholding for certain
payments, such as interest and dividends. Corporations are
not exempt from backup withholding for payments made in
settlement of payment card or third party network
transactions.
Note. If you are exempt from backup withholding, you should
still complete this form to avoid possible erroneous backup
withholding.
The following codes identify payees that are exempt from
backup withholding:
1 - An organization exempt from tax under section 501(a), any
IRA, or a custodial account under section 403(b)(7) if the
account satisfies the requirements of section 401(f)(2)
2 - The United States or any of its agencies or instrumentalities
3 - A state, the District of Columbia, a possession of the United
States, or any of their political subdivisions, agencies, or
instrumentalities
4 - A foreign goverenemtn or any of its political subdivisions,
agencies, or instrumentalities
5 - A corporation
6 - A dealer in securities or commodities required to register in
the United States, the District of Columbia, or a possession of
the United States
7 - A futures commission merchant registered with the
Commodity Futures Trading Commission
8 - A real estate investment fund
9 - An entity registered at all times during the tax year under
the Investment Company Act of 1940
10- A common trust fund operated by a bank under section
584(a)
11 - A financial institution
12 - A middleman known in the investment community as a
nominee or custodian
13 - A trust exempt from tax under section 664 or described in
section 4947.
The following chart shows types of payments that may be
exempt from backup withholding. The chart applies to the
exempt payees listed above, 1 through 13.
IF the payment is for. . .
THEN the payment is exempt for. . .
Interest and dividend
payments
All exempt payees except for 7
Broker transactions
Exempt payees 1 through 4 and 6
through 11 and all C corporations.
S corporations must not enter an
exempt payee code because they
are exempt only for sales of
noncovered securities acquired prior
to 2012.
Barter exchange
transactions and
patronage dividends
Exempt payees 1 through 4
Payments over $600
required to be reported
and direct sales over
$5,000
1
Generally, exempt payees 1 through
5
2
Payments made in Exempt payees 1 through 4
settlement of payment
card or third party
network transactions
1
See Form 1099-MISC, Miscellaneous Income, and its
instructions.
2
However, the following payments made to a corporation and
reportable on Form 1099-MISC are not exempt from backup
withholding: medical and health care payments, attorneys'
fees, gross proceeds paid to an attorney, and payments for
services paid by a federal executive agency.
Exemption from FATCA reporting code. The following codes
identify payees that are exempt from reporting under FATCA.
These codes apply to persons submitting this form for
accounts maintained outside of the United States by certain
foreign financial institutions. Therefore, if you are only
submitting this form for an account you hold in the United
States, you may leave this field blank. Consult with the person
requesting this form if you are uncertain if the financial
How to get a TIN. If you do not have a TIN, apply for one
immediately. To apply for an SSN, get Form SS-5,
Application for a Social Security Card, from your local
Social Security Administration office. Get Form W-7,
Application for IRS Individual Taxpayer Identification
Number, to apply for an ITIN or Form SS-4, Application for
Employer Identification Number, to apply for an EIN. You
can get Forms W-7 and SS-4 from the IRS by calling 1-800-
TAX-FORM (1-800-829-3676) or from the IRS’s Internet
Web Site www.irs.gov
.
If you do not have a TIN, write “Applied For” in the space
for the TIN, sign and date the form, and give it to the
requester. For interest and dividend payments, and
certain payments made with respect to readily tradable
instruments, generally you will have 60 days to get a TIN
and give it to the requester before you are subject to
backup withholding on payments. The 60-day rule does
not apply to other types of payments. You will be subject
to backup withholding on all such payments until you
provide your TIN to the requester. Note: Writing “Applied
For” means that you have already applied for a TIN or that
you intend to apply for one soon.
Enter the TIN which coincides with the 'Legal Name'
provided on the form.
a. If you are an individual, check the "Social Security
Number (SSN)" box and enter the SSN.
b. If you are a Grantor or Revocable Trust, check the
"Social Security Number (SSN)" box and enter the SSN of
the Grantor.
c. If you are a Resident Alien, check the "Social Security
Number (SSN)" box and enter your SSN or your ITIN (IRS
Individual Taxpayer Identification Number).
d. If you are a Sole Proprietor, check the "Social Security
business as (DBA)" name on the "Business Name" line.
Limited liability company (LLC). An LLC with at least two
members is classified as a partnership for federal income tax
purposes unless it files Form 8832 and affirmatively elects to
be treated as a corporation. Enter the name of the partnership
or corporation. An LLC with only one member is treated as an
entity disregarded as separate from its owner for income tax
purposes (but as a separate entity for purposes of
employment tax and certain excise taxes), unless it files Form
8832 and affirmatively elects to be treated as a corporation. If
you are a single-member LLC (including a foreign LLC with a
domestic owner) that is disregarded as an entity separate
from its owner, enter the owner’s name on the “Legal Name”
line. Caution: A disregarded domestic entity that has a
foreign owner must use the appropriate Form W-8.
Contact Information. Enter your contact information.
Enter your Legal Address. Enter your Remittance Address. A
Remittance Address is the location in which you or your entity
receives business payments.
Enter your Business Phone Number. Enter your Mobile Phone
Number, if applicable. Enter your Fax Number, if applicable.
Enter your Email Address.
For clarification on any of the fields, see www.irs.gov.
Exemptions
If you are exempt from backup withholding and/or FATCA
reporting, enter in the Exemptions box, any code(s) that may
apply to you. See Exempt payee code and Exemption from
FATCA reporting code.
Exempt payee code. Generally, individuals (including sole
proprietors) are not exempt from backup withholding.
institution is subject to these requirements.
A - An organization exempt from tax under section 501(a) or
any individual retirement plan as defined in section
7701(a)(37)
B - The United States or any of its agencies or instrumentalities
C - A state, the District of Columbia, a possession of the United
States, or any of their political subdivisions or
instrumentalities
D - A corporation in the stock of which is regularly traded on
one or more established securities markets, as described in
Reg. section 1.1472-1(c)(1)(i)
E - A corporation that is a member of the same expanded
affiliated group as a corporation described in Reg. section
1.1472-1(c)(1)(i)
F - A dealer in securities, comodities, or derivative financial
instruments (including notional principal contracts, futures,
forwards, and options) that is registered as such under teh
laws of the United States or any state
G - A real estabte investement trust
H - A regulated investment company as defined in section 851
or an entity registered at all times during the tax year under
the Investment Company Act of 1940
I - A common trust fund as defined in section 584(a)
J - A bank as defined in section 581
K - A broker
L - A trust exempt from tax under section 664 or described in
section 4947(a)(1)
M - A tax exempt trust under a section 403(b) plan or section
457(g) plan
Section 2 - Certification
To establish to the paying agent that your TIN is correct, you
are not subject to backup withholding, or you are a U.S.
person, or resident alien, sign the certification on Form W-9.
For a joint account, only the person whose TIN is shown in
Part I should sign (when required).
