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<br />~.~ <br /> <br /> <br /> <br />~.lltI41~ii'{,1 <br /> <br />(/ r"" <br />. .:----. .~ \. .. <br /> <br />~ ; :;.: ~ . ,. <br /> <br />c.s.:..... ~~f-l T.H.-6J)"W\ \r <br />R.P. \ , <br />D~(DttJcoMPil;icds~?C11~~~;C::iir;oIVL" <br /> <br />t...... <br />..~~.. <br />,.... <br /> <br />JUN <br /> <br />A1TACH A SKETCH OF THE PROPOSED WORK AND RELATION TO TRUNK HIGHWAY. SUCH SKETCH SHALL BE D. <br />TO SCALE WHEN REQUIRED BY THE ENGINEER. PRINT OR TYPE APPLICATION. SIGN IN SPACE PROVIDED. s( <br />TO LOCAL OFFICE OF MINNESOTA DEPARTMENT OF TRANSPORTATION. <br /> <br />. APPLICA'IT <br /> <br />TELEPHONE <br /> <br />ADDRESS (SuCCI. City, Slate, Zip) e.~ ~~E <br />\S'C\S),\t:.Jl.1\N. ~.. ~ 5r;~L: <br /> <br />-m <br /> <br />-W:Z-\(~\'A <br /> <br />PARTY PERFORMISG WORK <br /> <br />~~ <br /> <br /> <br /> <br />-14Lf3 <br />) 6;AM~ ') - (hAt'\~ <br />U::IRCLE Oi',E) (SPECIF1C ROAD, LAND~~. OR ROAD L"'TERSEC <br />1/1.. HI. N. . (~<O\~ LU-.JE\ANC> <br />Courny~.'\I~,<~lifc's6-s.E.W elF ~ C. ~"J~/~5S\~ <br /> <br />ADDRESS (Street. City, Sl3te, Zip) <br /> <br />LOCATION OF PROPOSED WORK <br /> <br />Highway ~W <br />NATURE OF WORK <br /> <br />~ <br /> <br />in tl6~~ I ~~ <br />'P1AN1~fJ~J:> . ~-r~ <br /> <br />%~ <br /> <br />ANp <br /> <br />~N:> <br /> <br />~N <br /> <br />SURFACE OR SHOULDER TO BE DISTURDED (Check Appropri3le Bo~es) <br /> <br />o Road....-ay <br /> <br />o Gravel <br /> <br />o Concrete <br /> <br /> <br />o Shoulder <br />I'o't,'l\JBER & SIZE OF ~CA V A TIONS <br /> <br />o Bituminous <br /> <br />one <br /> <br />WORK TO START ON (Date) <br /> <br />~ A~-D fl.AtJ <br /> <br />D-IE REQUIRED TO COMPLETE WORK <br /> <br /> <br />~UITHODOF~STAL~TION/CONSTRUCTION <br />~\ ,Ac.a:..t::J? A~ <br /> <br />tl/1i <br /> <br /> <br />''''. <br /> <br />\M <br /> <br /> <br />IS TRAFFIC DETOliR I'o"ECESSARY? CJ Yes <br />NO 1(NO <br />(IF YES, TRAFFIC CO:'IITROL PLA."i IS REQllRE <br /> <br />I. We, the undersigned, herewith accept the lerms and conditions of the rq:ulalions of the Commissioner of Transport:ltion and agree 10 IUlly comply Iherewith 10 the satisf3ction of <br /> the r. <br />Dcp:1rtmcnt of Tr.msportation. II is agreed Ih:II no work in connection .....ith this application will be SWted until the application is approved and the permil issued. II is further <br /> underslood thaI Ih <br />is issued subjC<"! 10 the approY:lI of loc:al city, village or borough ~uthorities having joim super-vision over said street or bighway ~nd subject 10 appliam's complianc~ ....;th the <br /> rules and regu <br />the M iMCSOta Environmental Quality Board and any other arrcclCd govemmcnC1\ agencies. <br /> <br />Furthcmiorc. except for negligcrtt acts of the Swc, its agems and employees, lite applicant or his agentS or comractor sh<IlI assume allliabiliry for. and $Ive the Stale. ilS agenlS <br /> and employees. <br />from, ~ny :lnd all cbims for d=ges, :lctions or caUSC$ of action arising out of the work 10 be done herein and the cominuing usage, constructing. rcconsuuctinlym:linl3ining and using <br /> <br />of"" 7 ~I ;;r~'''... ..,..... "M_.. J1. fWJIt- ~ - I . <br /> <br />~ I Dale p~ ~APPIJ(:arn <br />DO NOT "..-RITE BELOW THIS LINE <br /> <br />I'ER\JIT NOT VALID UNLESS <br />BEARING SIGNATURE AND NUMBER <br /> <br />AUTHORIZATION OF PERMIT <br /> <br />SEE REVERSE SIDE fOR PERT <br />REGl>1..ATIO:-iS .4>...1> LL\IITATI' <br /> <br />II is expressly urw.ICTSIOOd Iha1 this pennil is conditioned upon rcpl~ccmcnl or rcslomion or Ihe trunk highway 10 its original condition or 10 a satisf~clOry condition. ,hi consideration <br /> of the ar <br />agreemcnt 10 comply in all respects with the regulations of Ihe Commissioner of Transponation covering such operations, permission is hereb~' ,ral\led for the ....ork to be performed <br /> as dC'J <br />the above applicalion. said work to be performed in accordance with special provisionS as bereby stalctl: <br /> <br />.. <br /> <br />SEE A 17 ACHED SPECIAL PROVISIONS <br /> <br />/ <br />/ <br /> <br />All Work To Be Compleled By <br /> <br />D~te <br /> <br />~:- <br /> <br />4h J he:. <br />, , <br /> <br />Dale <br /> <br />l\UNNESOTA DEPARTMENT OF TRANSPORTATION <br /> <br />~ ~ ~'~. <br />u , IZ~ slgna~ <br /> <br />DlSTRIBllTlON <br />~rigin:llto Applicalll <br />o Area Maimenance Engineer <br />o Subarea Supervisor <br />o Ru:w\\-ay Rqul;uiuns Supervisor <br /> <br />DEPOSIT REQUlREl\IE."1S <br /> <br />DEPOSIT TI'PE <br /> <br />~ <br /> <br />Cashier's Check i <br />Certified Check 1/ <br />Money Order' <br />Bond , <br /> <br />o No Deposil Required <br />o Deposit Required in the Amount of S <br />Dale Deposil Received <br />Deposit 10 be rnumcdupon s:lllsractory completion of all work.. <br />