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Revised 06/21 <br />ORANGE COUNTY—DEPARTMENT USE ONLY <br />______________________________________________________________________________ <br /> <br />Party/Vendor Name: Christopher Sandt Party/Vendor Contact Person: Christopher Sandt Contact Phone: 919-245- <br />2583 Party/Vendor Address: 131 W. Margaret Lane City Hillsborough State: NC Zip: 27278 Department: Planning <br />Amount: $0 Purpose: Need Bonnie’s original signature and Witness’ original signature on NCDOT 3-Party <br />Encroachment Agreement Application for installing OWASA sewer stub-out to serve 7731 Rogers Road Budget <br />Code(s): #61370035-880000-10054 (Construction) Vendor # N/A (N/A if new vendor) Vendor is a BOCC <br />consultant? Yes No Contract Type: (Check one) New Renewal Amendment Effective Date <br />ASAP Approved by Board Yes No Agenda Date: --- For Section XIV. c. contracts only, Approved by <br />Board in Current FY Budget Yes No <br /> <br />This agreement is approved as to technical form and content and I as Department Director affirmatively state work on <br />this project has not been initiated prior to execution of the agreement: <br /> <br />Department Director’s Signature ________________________________________ Date: ________ <br />Agreements for emergency services or repair are not subject to the above affirmation. If services related to this <br />agreement have already begun or been completed please briefly describe the nature of the emergency condition that <br />was addressed: <br /> <br />Information Technologies <br /> <br />(Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is <br />approved as to information technology content and specifications: <br /> <br />Office of the Chief Information Officer___________________________________ Date: ________ <br /> <br />Risk Management <br /> <br />This agreement is approved for sufficiency of insurance standards, specifications, and requirements: <br /> <br />Office of the Risk Management Officer___________________________________ Date: _________ <br /> <br />Financial Services <br /> <br />This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: <br /> <br />Office of the Chief Financial Officer ____________________________________ Date: _________ <br /> <br />Legal Services <br /> <br />This agreement is approved as to legal form and sufficiency: <br /> <br />Office of the County Attorney __________________________________________Date: ________ <br /> <br />Clerk to the Board <br /> <br />Received for record retention: <br />All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov <br />The following signature block is for hard copies only and is not required for Docusign contracts: <br /> <br />Office of the Clerk to the Board __________________________________________Date:_________ <br />DocuSign Envelope ID: 269B2631-52B5-4390-B0FC-CE96792761B9 <br />10/14/2022 <br />10/14/2022 <br />10/14/2022 <br />10/14/2022