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MN/DOT 1723 (10/81) MINNESOTA DEPARTMENT OF TRANSPORTATION APPLICATION FOR PERMIT FOR INSTALLATION OF UTILITIES OR FOR PLACING OF OBSTRUCTIONS ON TRUNK HIGHWAY Control Trunk Section Hwy. Prepared in Triplicate.Forward or deliver all copies to proper District/Area Maintenance Office. District Permit No. No. Applicant Tel.No.�,, Address ..g , 4. -y1 t000 /. VI esu Lea- 71 _ c) 0/ III /t7 7y� Party,.• •orming work Tel.No. biz "fob keg.) yjf 'j/. / r/ I Nature of ork A. a II0 ... rubric ..k.,� i 1 Surface to be disturbedi_ a. / r .i d 3 )X 8� #a>7•Y)Cy 5c 0Concrete IIS shoulder to be disturbed •, 0Gravel (check one) 0 Bitum. •_a None — T.H. I County Municipality ❑ Yes :i No �t7 P;�) I Street or Ave. TY,.S ' // _ A .,' •- . Intersecting T.H. at: (ties - land or street lines)J ! ' A Zpy7, If � 0 T`H give t=shy motion, or land lines if rural G Size and d of pipe frn Depth ro.. surfac: '' t1 Z.-Ca-e.-t_��"4-- n� - I n/,q_ I No. and size of excavations Method of installation or construction ork to start on or after • it1 u . kl' 0 • _ .m U a LP F y, Q �n or I Timet required to complete work LJ�Tl," Cls'" Is traffic de -ur necessary If detour is necessary, describe rerouting _`� hd ❑ Yes No I, We, the undersigned, herewith accept the terms and conditions of the regulations of the Commissioner of Transportation and agree to fully comply therewith to the satisfaction of the Minnesota Department of Transportation. Furthermore, except for the 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, any and all claims for damages, actions or causes of action arising out of the work to be done herein and the continuing usage, constructing, reconstructing, maintaining and using of said utility under this application and Permit for construction. Dated 9—9 " fr- Applicant's 24 ,j Signature. -/`` , , gyp SEE REVERSE SIDE AUTHORIZATION OF PERMIT FOR REGULATIONS (PERMIT NOT VALID UNLESS BEARING SIGNATURE AND NUMBER) Permit No his In consideration of their agreement to comply in all respects with the regulations of the Commissioner of Transportation covering such operations, permission is hereby granted for the work to be done as described in the above application, said work to be done in accordance with special precautions required as hereby stated: It is expressly understood that this permit is conditioned upon replacement or restoration of the trunk highway to its original or to a satisfactory condition. It is further understood that this permit is issued subject to the approval of local city, village or borough authorities having joint supervision over said street or highway and subject to the applicant's compliance with the rules and regulations of the Minnesota Environmental Quality Board and any other affected governmental agencies. White copy to Applicant MINNESOTA DEPARTMENT OF TRANSPORTATION Green to Foreman Pink to District/Area Maintenance Engineer Dated Authorized uthoriThe date when work is completed must be reported w District/Area Maintena tce E gid eeaaure gneer Return this portion when work is completed: No Deposit Required Permit No For Deposit in Amount of ; Required and Attached Hereto. Date work completed District Cashier's Check No Use Only Or Certified Check No This Deposit Made by — Applicant Bond No.