S A M P L E

1.	Name and address of APPLICANT:

2.	Location where grading desired (legal description):

3.	Reason grading requested:

4.	It is understood and agreed by the APPLICANT that this Application is subject to the final approval of the Cheyenne County Highway Superintendent, and then, in that event such corrective grading shall be performed only at such time as shall be convenient for the County Highway Department.

5.	APPLICANT further agrees to be present at time of such grading and does further agree to indemnify and save the County of Cheyenne, the Cheyenne County Board, and any of the employees of the County of Cheyenne, harmless from any damage or injury to any person, including APPLICANT, occurring to any property, personal or real, sustained by any person, including APPLICANT, or to any person, while the corrective grading is being performed on the premises described above.

6.	The agreed rate shall be $55.00 per hour with a minimum of one hour and a maximum of two hours, to be permitted at any one time, and hourly rate shall be based upon a full hourly charge, any portion thereof shall be billed to the next full hour.


Application Valid Thru

Dated this		day of

APPLICANT




Operator:	COUNTY BOARD OF CHEYENNE COUNTY, NEBRASKA

Hours Required:

Date Completed:	BY:
		HIGHWAY SUPERINTENDENT