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Ma/D07 TP-1723(SHORT FORM PER30T)(40I)Revised 4-2003 0.0;- 3 Permit#3A-u 5'-O7—1�P 4 o 7 • District NEMESOTA DEPARTMENT OF TRANSPORTATION t c.s. / D T H_y Z J APPLICATION FOR INSTALLATION OF UTILITIES OR NIISCELLANEOUS WORK ON TRUNK HIGHWAY wr y�I.f� U�j RIGHT OF WAY MO NOT COMPLETE THIS SEC aON-FOR OFFICE USE ONLY) i TTACHA SKETCH OF THE PROPOSED WOR KANDRELATIONToTRUN%HIGHWAY. SUCHSEETCHSHALLBEDRAWNTO ""�SCALEWHENREQUIREDBY THE ENGINEER PRINTORTYPEAPPLICATION. SIGNINSPACEPROVIDED. SUBMITTOLOCAL OFFICE OF THE MINNESOTA DEPARTMENT OF TRANSPORTATION. APPLICANT TELEP O ADDRESS(Street,City,State,Zip) (f PARTY PERFORMING WORK TELEPHONE ADDRESS(Street,City,Sta LOCATION OF PROPOSED WORK J%VWECIFY ROAD IIV TE$SECTION OR LANDMARK) Highway�/ m ��J�;r �� cwr.wmhip t. Cry N-S-E-W of�7/ F' c, r IO 7 NATURE OF WORK N CQq-4••t d vT rr 4,0, e4-4,> Sf4,-a..,17,s_ SURFACE TO BE DISTURBED (Check Appropriate oxes) J ❑Roadway ❑Shoulder ❑Concrete ❑Bituminous ❑Gravel ?J2%Y1 �i.�r� JB'� J126�S �'/J J�� ,��' rr,oc� G+�2�Sf. ❑Turf only ❑Otha OY DEPTH OF EXCAVATION BELOW SURFACE NUMBER&SIZE OF EXCAVATIONS METHOD OF INSTALLATION/CONSTRUCTION rv- N WORK TO START ON OR AFTER WORK TO BE COMPLETED ON OR BEFORE IS TRAFFIC DETOUR NECESSARY? ❑Yes � ) !q � o f ttiai '%m q (Dam) (IF YES,TRAFFIC CONTROL PLAN IS REQUIRED) I, We, the undersigned, herewith accept the terms and conditions of the any and all claims for damages,actions or causes of action arising out of the Permit requirements of the Commissioner of Transportation and agree to work to be done herein and the continuing usage, constructing, fully comply therewith to the satisfaction of the Minnesota Department of reconstructing, maintaining and using of said utility/miscellaneous work Transportation. It is agreed that no work in connection with this under this application and permit for construction. application will be started until the application is approved and the permit ik issued. It is further understood that this permit is issued subject to the Dated this /2 . day of '. 200� approval of local city, village or borough authorities having joint -ipervision over said street or highway and subject to applicant's � ,mpliance with the rules and regulations of the Minnesota Environmental -° "Quality Board and any other affected governmental agencies. By Name-Print or Type Furthermore, except for negligent acts of the State, its agents and employees, the applicant or his agents or contractor shall assume all liability for, and save the State,its agents and employees, harmless from, Signature r v DO NOT WR><Tia BELOW TB7S LINE PERMIT NOT VALID E AND AUTHORIZATION OF PERNIIT SEE REVERSE SIDE FOR GENERAL BEARING SIGNATURE AND NUMBER INFORMATION AND REQUIREMENT 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 consideration of the applicant's agreement to comply in all respects with the regulations of the Commissioner of Transportation covering such operations,permission is hereby ngranted for the work to be pe_irfo_rmed as described in the above application,said work to be performed in accordance with special provisions as hereby stated. (�'m g1i'n 4e.1- 4l I�'Y mod/ ��(%K ,'/ � 1�n..o:rc+l fn.� lnt br"rll wha�— (�' f-CrirQ i-?,t cx S �f e, G-(7�l/�-J F`J- d 7 d 60 / Cx� fir^St`t� qvt Jan et '0cr..- .�Y1rV a`T 1'"°�7►�/ �n 4 �f t'Sots c am) /'r /ufps. p/e (0?",W't 51/)O,--LC-r 4 . A-454- Je q-t ' o S-7 -a7 Data All Work To Be Completed by A�,hasized MIYDOTSignatmv Date of Authorized Sipature DISTRIBUTION DRPOSrr REQUMEMENTS DEPOSIT TYPE Ori&d to Area Maintenance Engineer ❑p Deposits Raluhcd Cashiaes Check# Applicant D p= ag Lt in the Ammmt of S /. J�'OtJ. t�C1 c., s vlaot Date t RwA&ed Certified Cheek# away Regdatmos Supervisor Mandy Order# Deposit m be reaaaed upon atafiemry caorpletpa of all work gad# II LDA WORK COMPLETED a dare when the work is coxwleW assist be reParted to the local MAMOT Roadway Regulations Sf Ten6or. Page 1 oft n c`