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A TRUE COPY <br />CERTIFICATION ON LAST PAGE <br />STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION RYAN L. BUTLER, CLERhGTILIT E2 <br />UTILITY WORK BY HIGHWAY CONTRACTOR AGREEMENT OGC-0619 <br />(AT UTILITY EXPENSE) <br />reference purposes only and do not change the terms of the document. By signing this document, the UAO <br />hereby represents that no change has been made to the text of this document except through the terms of the <br />appendix entitled Changes to Form Document. <br />You MUST signify by selecting or checking which of the following applies <br />❑ No changes have been made to this Form Document and no Appendix entitled "Changes to Form <br />Document' is attached. <br />® No changes have been made to this Form Document, but changes are included on the attached <br />Appendix entitled "Changes to Form Document." <br />IN WITNESS WHEREOF, the parties hereto have executed this Agreement effective the day and year first written. <br />UTILITY: Indian River County Department of Utility Services <br />BY:(Signature) DATE: <br />(Typed Name: ) <br />(Typed Title: ) <br />Recommend Approval by the District Utility Office <br />BY: (Signature) DATE: <br />FDOT Legal review <br />BY: (Signature) DATE: <br />District Counsel <br />STATE OF FLORIDA <br />DEPARTMENT OF TRANSPORTATION <br />BY: (Signature) DATE: <br />(Typed Name: _John P. Krane, P.E.) <br />(Typed Title: Director of Transportation Development <br />FEDERAL HIGHWAY ADMINISTRATION (if applicable) <br />BY: DATE: <br />(Typed Name: ) <br />(Typed Title: ) <br />Page 9 of 10 <br />