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Mn/DOT TP-1723(SHORT FORM PERMIT)(12-08)
<br /> Document Management System#
<br /> �'tN�OT4 J
<br /> MINNESOTA DEPARTMENT OF TRANSPORTATION v° District Permit# 14 —Lt S i0
<br /> APPLICATION FOR INSTALLATION OF UTILITIES ` C.S.. /9/0 T.H. J f'
<br /> OR MISCELLANEOUS WORK ON TRUNK
<br /> HIGHWAY RIGHT OF WAY OF TF R.P. t.09 Y�- Y,c4
<br /> (DO NOT COMPLETE THIS SECTION. FOR OFFICE USE ONLY)
<br /> ATTACHA SKETCH OF THE PROPOSEDWORKANDRELATIONTOTRUNKHIGHWAY. SUCIISKETCH SHALL BE DRA WN TO SCALE WHEN
<br /> REQUIRED BY THE ENGINEER.PRINT OR TYPE APPLICATION. SIGNINSPACEPROVIDED. SUBMIT TO LOCAL OFFICE OFMINNESOTA
<br /> DEPARTMENT OF TRANSPORTATION.
<br /> APPLICANT TELEPHONE ADDRESS (Street,City,State,Zip)
<br /> �ly ST(l 4610 �Pv
<br /> PARTY PERFORMING WORK TELEPHONE ADDRESS(Street,miry,State,Zip)
<br /> 52-Ary &-C� vAT� et/y ��I ��� 7d 3 30 03 Pt '
<br /> /<;V e< .v .S7`� f
<br /> LOCATION OF PROPOSED WORK (City/Township) (County) (Distance) (N-S-E-W) SPECIFIC ROAD INTERSECTION OR LANDMARK
<br /> Highway 371 in A,0 04! � ,o C re 1✓ AV 1"V ► � Mies Sf v rh of 5!, 4 I7 T
<br /> NATURE OF WORK LeVe-L1 ylJy Alv d SURFACE TO BE DISTURBED (Check Appropriate Boxes)
<br /> 1-0 ❑Roadway ❑Shoulder ❑Concrete ❑Bituminous ❑Gravel
<br /> CXPEA160- m1gl t if 9,4r /- A14y MiVA044 E]Turf Only E]Other
<br /> DEPTH OF EXCAVATION BELOW SURFACE NUMBER&SIZE OF EXCAVATIONS METHOD OF INSTALLATION/CONSTRUCTION
<br /> /tl�} IVA- Qa bch•r
<br /> WORK TO START ON OR AFTER WORK TOO B(E`COMPLETED BY IS TRAFFIC DETOUR NECESSARY? []Ye s ❑No
<br /> (Date) (Date) if- (IF YES,TRAFFIC CONTROL PLAN IS REQUIRED.)
<br /> I,We,the undersigned,herewith accept the terms and conditions of the permit requirements of the Commissioner of Transportation and agree to fully comply therewith to
<br /> the satisfaction ofthe Minnesota Department ofTransportation. It is agreed that no work in connection with this application will be started until the application is approved
<br /> and the permit issued. It is further understood that this permit is issued subject to the approval oflocal city,village or borough authorities having joint supervision over said
<br /> street or highway and subject to applicant's compliance with the rules and regulations of the Minnesota Environmental Quality Board and any other affected governmental
<br /> agencies.
<br /> Furthermore,except for negligent acts of the State,its agents and employees,the applicant or his/her agents or contractor shall assume all liability for,and save the State,its
<br /> ents and employees,harmless from,any and all claims for damages,actions or causes of action arising out of the work to be done herein and the continuing usage,
<br /> Instructing,reconstructing,maintaining and using of said utility/miscellaneous work under this application and permit for construction.
<br /> Name and Title r l ��r�`— Email address�` t •� l'9G e ,!�i �>'�• �G
<br /> (Print or Type)
<br /> Date �r-t/ Signature
<br /> DO NOT WRITE BELOW THIS LINE
<br /> PERMIT NOT VALID UNLESS SEE REVERSE SIDE FOR PERTINENT
<br /> BEARING SIGNATURE AND NUMBER AUTHORIZATION OF PERMIT REGULATIONS AND LIMITATIONS
<br /> It is expressly understood that this permit is conditioned upon replacement or restoration of the trunk highway to its original condition or to a satisfactory condition. In
<br /> consideration of the applicant's agreement to comply in all respects with the regulations of the Commissioner of Transportation covering such operations,permission is
<br /> hereby granted for the work to be performed as described in the above application,said work to be performed in accordance with special provisions as hereby stated:
<br /> SEE ATTACHED SPECIAL PROVISION
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<br /> i,A,ji-t r1` mor ty\o---bie, rv- Ji'etr.e-f5 r -fh-e ' 5-0t b� c,-
<br /> -Z--v !to u;� a L?� IAO 1� re VC,-v r- cry dt:�7...a J C �i,-,7 o f
<br /> r5 Uri 1=�W I cu l Eti'�;>� Sly�I 1 �,�1°, Jj /�i �G► O/ 51ty-NC,i/ P Ul,j.'lI+CN�.
<br /> Date All Work To Be Completed By Authorized Mfi/DOT Signature V Date of Authorized Signature
<br /> DISTRIBUTION DEPOSIT REQUIREMENTS DEPOSIT TYPE
<br /> `riginal to Area Maintenance Engineer >No Deposit Required Cashier's Check#
<br /> )Iicant ❑Deposit Required in the Amount of S Certified Check#
<br /> ubarea Supervisoa w J4 S�Tre#,,A,4-, Date Deposit Received Money Order#
<br /> Roadway Regulations Supervisor Deposit to be returned upon satisfactory completion of all work Bond#
<br /> DATE WORK COMPLETED �^ The date when the work it completed must be reported to the local MkIDOT Roadway Regulations Supervisor.)
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