Application to Occupy Right of Way
Applicant: (Name and Address)	Date:
Phone:
Fax No.:
Email:
Type	With a	Size	Material Type
Overcross	Water Line Wireless Infrastructure
Undercross	Sewer Line
Occupy	Gas Line
Miscellaneous	Telephone Line Underground Aerial
Temporary Irrigation Pipe Crossing (Remove by October 15th this year)
Electric Line Underground Aerial
If aerial, type of Section: Ditch Curb Speed Limit: mph
Tree Trimming/Tree Removal Grading Other

Location: beginning	feet East West North South of the East West North
South Line of Section	, Township	North, Range	East West of the 6th P.M.,
County, Nebraska. This is also	feet East West North South of Milepost
No.	on the East West North South side of Highway No.	. If the application is to
“occupy,” the work extends	feet East West North South .

Requirements: The applicant agrees to complete this work in accordance with the terms and conditions of the Nebraska Department of Transportation. Any permit issued will be cancelled if the work specified is not completed within the term listed on the permit or within any additional length of time granted. Request for an extension of time to complete the work must be made in writing. Any extension granted will be acknowledged in writing by the Nebraska Department of Transportation. The Applicant may cancel the permit with written notification at any time prior to beginning work on highway right of way.

Performance Guarantee: (Make payable to Nebraska Department of Transportation)
Amount: $	Check/Account No.
Name and Address:
This guarantee is for the faithful compliance by the Applicant to the terms of the permit. It is understood that should the Applicant fail to perform the work as set forth in the permit, the State will have the right to keep the performance guarantee as liquidated damages for its necessary supervisory and inspection expenses and to initiate such legal proceedings as are necessary to secure either performance of the work in compliance with the terms of the permit or the restoration of the highway right of way to its previous condition prior to the activities of the Applicant.

NOTE: Please complete the appropriate location plan attached for overcross or undercross of location to occupy state right-of-way. When your project requires engineering plans, please submit two sets of plans, no larger than 12”x18”. The engineering plans shall show the general features of the work to be completed and all information such as sizes, distances, dimensions, cuts and fills, erosion control measures, etc., when applicable.
Name (Please Print)	Applicant’s Signature
Recommended By	Date	District Engineer Approval	Date

District Recommendations:

For NDOT Use Only Highway Right-of-Way Use Agreement #____________________ Wireless Infrastructure Agreement #________________________

NDOT Form 19, April 2020

Location Plan for Overcross or Undercross

Note:	All applicants must use this plan and fill in the required information.

Section	Township	Range	County
Indicate North

Milepost	Milepost
section line	section line
Distance to closest milepost
Ft.	Ft.
No.	No.
Centerline
Hwy. No.
Distance to closest section line
Ft.	Ft.
WORK AREA point of road to be crossed

Note:	The following information is required on all plans:

Highway number

Distance in feet to nearest section line

Distance in feet to nearest milepost

Complete legal description, including section, township, range, and county

Designate North direction

Location Plan to Occupy State Right of Way

Note:	All applicants must use this plan and fill in the required information.

Section	Township	Range	County
Indicate North

x--- x--- x--- x--- x--- x--- x--- x--- x--- x--- x--- x--- x--- x -ROW ---x--- x--- x--- x--- x--- x--- x--- x--- x--- x--- x--- x--- x--- x

section line	Distance from ROW to Work Area	section line
Ft.
Distance from Work Area to Centerline
Ft.
Work Area
Starting Point
Total Length of Work Area
Starting Point
Ft.
Centerline
Hwy No.	Ft.
Total Length of Work Area
Ft.	Ft.
Distance to nearest section line
Milepost	Milepost
- x -	-- x --- x --- x --- x --- x --- x --	- x --- ROW --- x --- x --- x --- x --- x -	-- x --- x --- x --- x --- x --- x --- x -
Ft.	Ft.
Distance from Starting Point of Work Area to Closest Milepost
No.	No.

Note:	The following information is required on all plans:

Highway number

Distance in feet to nearest section line

Distance in feet to nearest milepost

Distance in feet to State ROW

Distance in feet to centerline

Total length of work area

Complete legal description, including section, township, range, and county

Designate North direction