HomeMy WebLinkAboutConcurrence for Temp. Use of City Streets - Wayne St. - INDOTCONCURRENCE FOR TEMPORARY USE OF CITY OR COUNTY STREETS OR
ROADS FOR THE DETOURING OF TRAFFIC FROM A STATE HIGHWAY
** TO BE ATTACHED TO STATE FORM 41769R**
December 2004
Detour requested to be used
It is agreed that repair of any damages to county roads, city streets, intersections, public or private property and/or
drainage caused by this road closing and/or detours will be the responsibility of:
COUNTY HIGHWAY DEPARTMENT
CITY STREET DEPARTMENT
TOWN BOARD OF TRUSTEES
THE APPLICANT AGREES TO INDEMNIFY, DEFEND, EXCULPATE, AND HOLD HARMLESS THE
STATE OF INDIANA, IT’S OFFICIALS AND EMPLOYEES FROM ANY LIABILITY DUE TO LOSS,
DAMAGE, INJURIES OR OTHER CASUALTIES OF WHATSOEVER KIND, OR BY WHOMEVER
CAUSED TO THE PERSON OF PROPERTY OR ANYONE ON OR OFF THE RIGHT-OF-WAY
ARISING OUT OF, OR RESULTING FROM THE ISSUANCE OF THIS AGREEMENT OR THE WORK
CONNECTED THEREWITH, OR FROM THE INSTALLATION, EXISTANCE, USE, MAINTENANCE,
CONDTION, REPAIRS, ALTERATION, OR REMOVAL OF ANY EQUIPMENT OR MATERIAL.
WHETHER DUE IN WHOLE TO THE NEGLIGENT ACTS OR OMISSIONS (1) OF THE STATE, IT’S
OFFICIALS, AGENTS OR EMPLOYEES; OR (2) OF THE APPLICANT, HIS AGENTS OR
EMPLOYEES OF THE PERSONS ENGAGED IN THE PERFORMANCE OF THE WORK, OR (3) THE
JOINT NEGLIGENCE OF ANY OF THEM: INCLUDING ANY CLAIMS ARISING OUT OF THE
WORKMAN’S COMPENSATION ACT OR ANY OTHER LAW, ORDINANCE, ORDER, OR DECREE.
THE APPLICANT ALSO AGREES TO PAY ALL REASONABLE EXPENSES AND ATTORNEY FEES
INCURRED OR IMPOSED ON THE STATE IN CONNECTION HERE WITH IN THE EVENT THAT
THE APPLICANT SHOULD DEFAULT UNDER THE PROVISIONS OF THE PARAGRAPH
COUNTY OF , BOARD OF COMISSIONERS BY:**
1.
2.
CITY OF BY:**
1.
2.
** DENOTES (2) MEMBER SIGNATURES ARE REQUIRED**
**DEPARTMENTAL USE ONLY**
Recommendation Approval Approval
71 - St. Joseph State Road 933 (Main St.)
Application/Permit Number County Number Road to be Detoured
NB: Wayne St. to Lafayette Blvd. to Jefferson Blvd. SB: Jefferson Blvd. to Dr. MLK Jr. Blvd. to Western Ave.
City of South Bend
March 28, 2023
BOARD OF PUBLIC WORKS
AGENDA ITEM REVIEW REQUEST FORM
Date 03/27/2023
Name Zach Hurst Department DPW
BPW Date 03/28/2023 Phone Extension 3057
Review and Approval Required Prior to Submittal to Board Diversity Compliance
and Inclusion Officer Officer Name BPW Attorney Attorney Name
Dept. Attorney Attorney Name
Purchasing
Check the Appropriate Item Type – Required for All Submissions
Professional Services Agreement Contract Proposal
Open Market Contract Amendment/Addendum Special Purchase, QPA
Bid Opening Bid Award Req. to Advertise Title Sheet
Quote Opening Quote Award Reject Bids/Quotes
Proposal Opening C/O & PCA No. PCA
Chg. Order, No. Traffic Control Resolution
Other: Concurrence for
Temporary Use of City Streets
Ease./Encroach
Required Information
Company or Vendor Name INDOT – LaPorte District
New Vendor Yes If Yes, Approved by Purchasing
No
MBE/WBE Contractor MBE
WBE Completed E-Verify Form Attached Yes
No
Project Name Norwest Parking Garage Street Closures
Project Number
Funding Source
Account No.
Amount
Terms of Contract
Purpose/Description Indemnification form to hold harmless INDOT for City allowing its streets to
be used as state detour route for Main Street closure relating to debris
concerns with Norwest Parking Garage.
For Change Orders Only
Amount of
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($ )
Previous Amount $
Current Percent of Change:
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New Amount $
Total Percent of Change:
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Time Extension Amount:
New Completion Date: