application to MnDOT for ROW work

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ro�m iit��o-to-tui�) Document Management System# MINNESOTA DEPARTMENT OF TRANSPORTATION `�N�'� D;Sn;�t Pe,m;�p APPLICATION FOR MISCELLANEOUS WORK ON � TRUNK HIGHWAY RIGHT OF WAY C.S. T.H. � R.P. (THIS SECTION FOR MnDOT OFFICE USE ONLY.) ATTACH A SSETCH OF THE PROPOSED WOR%AREA AND RELATION TO TRUNR HIGHWAY. SUBMIT TO DISTRICT PERMIT OFFICE OF MlNNESOTA DEPARTMENT OF TRANSPORTATION. APPLICAN'f TELEPHONE ADDRESS(Street,City,State,Zip) �ev�. Ci�.r�2 �c,.rl�c�� s (�12-13J-�1`1('� 36�G' =1a�abs M� Rd'� �rvti.� � �UIFJ SS35� PARTY PERFORMING WORK TELEPHONE ADDRESS(Street,City,State,Zip) j53�� �r�-�vr� 7`�'.�s b l2-Z�Z-�'l2-I 33� �f� 5�--. �t� �ac�a p�t�` LOCATION OF PROPOSED WORK (Ciryt1'ownship) (Co�mry) (D�stance) (N-S-E-� SPECIFIC ROAD INT ECl'IO O LANDMARK �2�:� � f �,��.� r��' � � ��.� �z Hi wa in ' �� i� � Miles �'�'� of (�, , WII.L TffiS FACILITY BE WITHIN TRIBAL LANDS? ❑Yes ❑No IF YES,WFIICA ONE? NATURE OF WORK � r ��cc�,�v��=�5 �u 6�oc.k p ur' �(.2c.tr U �w y � a� lZ ��(�v�SS �v��r�� � �F �� 25--x� �c� � n bi�� t �es SURFACE TO BE DISTURBED (Check Appropriate Boxes) J� �i ❑Roadway ❑Shoulder ❑Concrete ❑Bituminous ❑Gravel [�''�urf Only �� n�� 6 ��(�"�- -�r��-i_�'�� ' ❑Other(explain) '"1 73W►-�'� LY�s� �d� ��"^ S� GT �►Gc DEPTH OF EXCAVATION BELOW NUMB�,EoR� &SIZE OF E CAVA NS METHOD OF INSTALLA ON/CONS CTION SURFACE (_ ('_ L �t�Z �v-�' l�(�f ` �Q� �6�2 �G�Qf^ ��i'�Q :5,��l�c� {C 'r�2.1 WORK TO START ON OR AFTER WORK TO BE COMPLETED BY IS TRAFFIC DETOUR NECESSARY? Yes No l�C/1(�,,�� i:e-�f'►�l7�-I� IS`` (tF YES,TRAFFIC CONTROL PLAN IS REQUIRED.) APPLICANf'S ACCEPTANCE,WAIVER AND INDENINIFICATION The undersigned applicant 6ereby agrees to comply with appGcable atatutes,rules,and the standard conditions and speciai provisions of this permiw The applicant understands and agrees that no work in connection with this application will be started uMil the applicallon has been approved and the permit issued. The applicant is aware of circumstances or hazards that may arise while performing the work associated wit6 tlus application that could result in injury,loss,damage or desth,and the applicant assumes the risk of such circumstances,dangers and hazards,whether reasonably foreseeable or nok The applicant also understands that this permit may also be subject to the approval of local road authorities having joint aupervision over said atreet or highway,and may be subject to appGcant's compliance with the rules and regulations of the Minnesota Environmental Quality Board and/or any other affected governmental agencies. The undersigned applicant expresaly agrees t6at except for negligent acts of the State,its agents and employees,the applicant or his/her agents or contractor shsll assume all liability for,and save the State,its agents and employees,harmless from any and all clsiros for damagea,actions or causes of action arfsing out of the work to be done in connectlon with this application and permit NAME AND 7'TTLE EMAIL ADDRESS �lllFF� �� •-�1f�5, �C.� �![`��5��, � / DATE (�! � ( SIGNATURE ��/��s� ' DO NOT WRITE BELOW THIS LINE PERMIT NOT VALID UNLESS BEARING AUTHORIZED MnDOT SIGNATURE AND PERMIT NUMBER AUTHORIZATION OF PERMIT It is eapressly understood that this permit is conditioned upon restoration of t6e trunk highway right-of-way to its original condition or to a satisfactory condition. In consideration of the applicant's agreement to comply in aii respects with the applicable laws and the conditions of the Commissioner of Transportation pertafning to this permit,permission is hereby granted for the work to be performed as described in the above application,sald work to be performed in accordance with the following standard conditions and special provisions: SEE ATTACHED STANDARD CONDTTIONS AND SPECIAL PROVISIONS Date All Work To Be Com leted B Authorized MnDOT Si ature Date of Authorized Si ature DISTRIBUTION DEPOSIT REQUIREMENTS DEPOSPT TYPE Original to Area Maintenance Engineer ❑ No Deposit Required Cashier's Check# Applicant ❑ Deposit Required in the Amount of$ Certified Check# Subarea Supervisor Date Deposit Received Money Order# Roadwa Re 13tions Su ervisor Depaslt w be returned upon satujactory complelion ojall work Bond# DATE WORK COMPLETED The date when the work is com leted must be re orted to the MnDOT District Pe�mrts O ice) Pape 1 nf 2