Blank Indiana State 415 23 PDF Template
The Indiana State 415 23 form, commonly referred to as the Permit Bond, serves a crucial role in the regulatory framework of construction and excavation activities within the state. This form is primarily utilized by individuals or entities applying for permits related to various projects, such as driveway excavations, pole line installations, and bridge attachments. The document establishes a financial guarantee, binding the applicant, known as the Principal, and their Surety to the State of Indiana. It ensures that the Principal will adhere to the terms of the permit and fulfill all obligations, including the payment of claims from contractors, vendors, and laborers involved in the project. Should the Principal fail to comply with the permit conditions, the Surety becomes liable for the financial repercussions, including court costs and attorney fees, up to the penal sum specified in the bond. The form requires signatures from both the Principal and Surety, along with notarization, to validate the agreement. Additionally, it includes sections for the application number, road number, and other essential details, ensuring that all parties are clearly identified and that the bond is appropriately recorded. This document not only protects the interests of the state but also provides a layer of security for those involved in construction projects, fostering accountability and compliance within the industry.
Form Sample
PERMIT BOND
State Form 415 23 (R4 /
Approved by State Board of Accounts, 2000
STATE OF INDIANA
DEPARTMENT OF TRANSPORTATION
Driveway |
Excavation |
Pole Line |
Bridge Attachment |
Misc.____________________ |
Know all men by these presents that we, the Undersigned _________________________________________
(address) ___________________________________________________________________as Principal and
_________________________________________________________________________________________
(address) ___________________________________________________________________as Surety, are
hereby held and firmly bound unto the State of Indiana in the penal sum of ____________________ , for the
payment of which well and truly to be made, we hereby jointly and severally bind ourselves, our heirs, executors, administrators successors and assigns:
DATED THIS ____________________________________ .
The conditions of the above obligation are such that, whereas, the above named _______________________
_________________________________________________________________________________________
did on ____________________________________ make application for a permit with the State of Indiana for:
__________________________________________________________________________________________
__________________________________________________________________________________________
which permit is made a part of this bond the same as though set forth herein.
Now, if said ________________________________________ (Principal - Applicant) shall well and faithfully do
and perform the things agreed by the _________________________________________ (Principal - Applicant)
to be done and performed according to the terms of said permit and to the satisfaction of the Indiana Department of Transportation, and shall pay all lawful claims of the contractor, vendors and laborers for labor performed and materials furnished, or other services rendered in the carrying forward, performing and completing of said permit, (on file with the Department of Transportation), then this obligation shall be void, otherwise the same shall remain in full force and effect, it being expressly understood and agreed that the liability of the Surety for any and all claims hereunder except as provided below shall in no event exceed the penal sum of this obligation as herein stated. In event of noncompliance the surety shall be liable for the court costs and attorney fees spent in the collection of this bond over and above the penal sum of this obligation.
IN WITNESS WHEREOF, we hereunto set our hands and seals this _________________________ day of
___________________, 20 ____ |
|
__________________________________________ |
_____________________________________________ |
__________________________________________ |
_____________________________________________ |
Surety |
Principal |
(Attach Power of Attorney) |
|
State of __________________________________ , |
County of _________________________________ ss: |
Personally appeared before me, ____________________________________________________________
______________________________as Principal and______________________________________________
___________________________________as Surety and each acknowledged the execution of the above bond
this___________________day of _______________________ , 20______
Witness my hand and _________________________________seal the said last named date.
My Commission Expires______________________, 20_____ |
_____________________________________ |
|
|
|
Notary Public (Written Signature) |
I reside in _____________________________County, ______ |
_____________________________________ |
|
|
(State) |
Notary Public (Printed or Typed Name) |
Bond number |
NOTICE OF TERMINATION OF LIABILITY |
|
□COMPLIED □ CANCELLED ___________________________________, 20 _____
DATE
Submit all 5 copies By: ___________________________________________________________________
PERMIT MANAGER
Application number
Road number
County number Received date
Issue date
Permit number
Form Specifics
| Fact Name | Description |
|---|---|
| Form Title | The Indiana State Form 415 23 is known as the Permit Bond. |
| Approval | This form was approved by the State Board of Accounts in the year 2000. |
| Governing Law | The form is governed by Indiana state law, specifically related to permits issued by the Department of Transportation. |
| Purpose | This bond ensures that the principal will fulfill obligations related to driveway excavation, pole line, bridge attachment, or other miscellaneous permits. |
| Liability | The surety is liable for claims up to the penal sum stated in the bond, covering payment for labor and materials. |
| Noncompliance Consequences | If the principal does not comply, the surety may be responsible for court costs and attorney fees beyond the penal sum. |
| Execution | The bond must be signed by both the principal and the surety, and it requires a notary public for validation. |
| Submission Requirements | Five copies of the completed form must be submitted to the Permit Manager along with the application number and other details. |
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