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111171v Z)4,�-7 7 - <br />mac m) (saaaoe) <br />0oaummn hlnntgemaM Sydow 4 <br />MINNL5 PORTATION <br />Diadct Pemhhd <br />iMON FOR MISCR ANE, OV <br />ApRLICATION FOR MIBCJ';LLANEOUS WORK ON <br />� <br />TRIJNXHIGHWAYRIGHT OF WAX <br />C.S. T.H. <br />(TWISSECTJONFOR "iDOTOFMCG USG ONLY) <br />AYTACfTA SA'RY'CITOTYMPROPOSRD IPORKARNAAND <br />J1R TIONTO MIZIff MOBIM <br />SART JIT TO D.7ST 127CT PJ3I L}p7' OI•'F1CS OP �1 JJNNR.SOTA <br />bTqiP�ARgT�iI /R@Ni�T OePtTQRilAyNSPORT(Ap)Y70N. <br />APPLICANT <br />TELEP80NE <br />200D7Xth AVemS� MIhI$IBPm�0119 MN 66415 <br />National Ms Society <br />612-965.7967 <br />PARTYPERPOIUMPIGIVORIC <br />TELEPHONE <br />Sfap)A SS fairest, City, Stam, Zip) <br />Scott Ahlgren <br />612-395-7967 <br />LOCATIONQFPROPOSEDWOIHL (caytmrm Nly) (couehy) eco..) pss lltvh grgAIt'I'dCiil (lino MTEE8ECTION OR LAN.DhfARfC <br />Rinliwa 61 In Hinckley to W Bear Lake 76 Miles North H of F <br />IMILTWSL'ACIL,rXY IYITEDt•ITRIBALLANDS7 _. Yes MNo IF 7'RS WkIICRO Gp <br />MVP`VORTC <br />eRe Tour using some shoulders on 61 and some (tells In Me, chlsago, Washington & Ramsay Counties. (Counlles also contacted) <br />SORIIACETOBEDISTURBED (CheoltAptimprlat§BoxeA) <br />[1Readwgy 111111shoollifier []Conorelo QBituminous QGravel El TavOhlly <br />❑ 0ther (oxpfatp <br />DEPTH OF EXCAVATION IMLONY <br />NUMBER& SIZE OF EXCAVATIONS <br />AIETRODOFRVSTALLATtiv/47ONSTRUCTI0 <br />SURFACE <br />R'ORICTOSTARTONORA' R <br />M1RICTOBECO TED Ey <br />ISTRAFFICDETOVILMUSSARYy YO ANo <br />June 12, 2016 <br />June 12, 2016 <br />EY Y18, TRAFFIC CONTROL PLAN ISREQ=FD,) <br />ARPLICANT-S ACCEPTANCE, WAIVER AND INDEhINWCATION <br />The undersigned Appllcapt hereby agree to comply with Applicable statutes, roles, And IN sfaudard conditions and spechil provisions of flits permit The applicants <br />understmnds and agrees that no Wait( fit 0011U00011 Will this applieAffon hill he started until the appilcatimn has been Approved and Ilio Permit issued, <br />The applleaut is moan pf elrmnnstancos or haurds that my n4o lvhilc poformlgg tho warlt pssoofulcd with tide appllentan ilia( could rCeult in hQuily, loss, damage <br />o1' death, And the applleAnt Agitates (he Asher sudh Circumstances, danger's And hazards, whether removably libruceahlo or not. <br />The Apbltennt also understands that this pel'mit may also be sublets to the spprowl ethical road authorities havlbg Johhl SnpahNisfon overbold st-Aht or blghlvap, nod <br />may be sabjedt to AllpPeantle complionoo with 1110 rates and ragulntfons at the Mhmeaoto Environmental Quality noard mrdlor Any class' affected governmental <br />"geleteA. <br />The undersigned applicantexplessly Agreas that excepf for negligentacls of IIID State, its Agools and ollploydes, I60 Applicant of his/her agents or` contractor shell <br />"snake All liability for•, Andsave ilia Slate,11a agents and employceS, lmfmieds from any and at ehAhshs far dalllaill Actions on' Causes of action m'ishi ff out of the wart( <br />to be done In connoetf nt wlllh this applieallon And permlt <br />NAME AND TITLE <br />ENTAIL ADDRESS <br />ScaltAhigren - Routes & Safety Speoiallst <br />scolt.shigran @nmss,org <br />April 26, 2016 <br />DATE <br />SIGNATURE <br />pONOT lYR1Yb'RJsZOJPzffiS rrArm <br />P.G NOT YAM r7NLGSSD NOdQYYTDRIZIt71MnDOTSTONATUR&ATID .ERMJTNtfhfBFR <br />ABTH0=ATY0N 6b'M1vHT <br />Ilia arpmasiy uhdoatood that thhspm'ndl is conditlon¢d Upon resioratoa cribs Irunlcldghway rlghbof lyAp to Its original eonalt8u or to A satisfactory condition. In <br />consideration of the appllcouPs Agreepmul to con)ply In All rrspeets Wth the applicable Imes and ilia cordltana of the Commissioner oPh•Ansphrtatmh parmhdng to <br />this peronih po missin is hereby granted for ilia lyorh.to In, po'farl ted As dosm'IbcdIn 1110 Abovt applleatoa, sold wm9cto be performed ht acem'dauce wilh file <br />follonbagstandard conditions And special Provisional <br />lift ATTACBED STANDARD CONDITIONS AND SPICCIALRRO175TONS <br />DamAil Wodcl'oB Com IeledB' <br />AutunlzedWiDOTSI mture <br />Data ofAuthorIzed Signature <br />DISTRIBUTION <br />DAPQ%TXMQ11H%MRNTE <br />_ <br />pEPOSIITTYPE <br />Orlglnnl to AvgMafutenahnee Rngincer <br />[I No.Depositltequired <br />Cashless Check# <br />Applicant <br />U DeposltRpqulmdhnihe Anloentof$ <br />0artified Check* <br />Sulmot Supervisor <br />Date Depose Reeamd. <br />Many Orderil <br />RoadwayR 4ledone Su eNlsor <br />PeyAt111e be whoukalwallaahj`jnrioq,ap nplallon nlhlrork <br />Band# <br />DATA11'ORIC COMPLETED Tile dole mhell file Ivorkfs corn hltedmastbereversed to flle.dDIDOTD1s/19cIPervills, O me) <br />Page I oft <br />