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Form►723(626-2013) Document Management System# Mll�iNES03'A DEPARTMENT OF TRANSPORTATION �' D;Su�� P�,,,;i# APPLICATION FOR MISCELLANEOUS WORK ON TRUNK HIGHWAY RIGHT OF WAY C.S. T.H. � R.P. (THIS SECTION FOR MnDOT OFFICE USE ONLY.) ATTACHA SSETCH OF THE PROPOSED WORgAREA AND RELATION TO TRUN%HIGHWAY. SUBMIT TO DISTRICT PERMIT OFFICE OF MINNESOTA DEPARTMENT OF TRANSPORTATION. APPLICAN'f TELEPHONE ADDRESS(Street,City,State,Zip) �`ev e, ao.e'1 $�-,.r�a� Ca I(i�s (,l 2-�3J-1`1�1 36 Bp Jacah s Ivt�Gi R�� G,rv,�a � AArJ SS35� PARTY PERFORMING WORK TELEPHONE ADDRESS(Sk�eet,City,State,Zip) �f�.-Gvrk- rt�s 6 t2�-ZgZ-�'lZi � �,�3� 33� � �-�--. �� 1?�o.Pawo � LOCA i 2 OF PROPOSED WORK (Ciry/Iownship) (Co�mry) (Dietence) (N-sE-� SPE�FI N R AD INT� ,ECfIO�i O�LANDMARK Hi wa �� in L.LCl�c EYI Y�i°� 1Vl � ��" L�u w� �1dC (Q <.t«.( t-hr:r.� 1Z Miles of (,..�t WII.L THIS FACILTTY BE WITHIN TRIBAL LANDS? ❑Yes ❑No IF YES,WffiCH ONE? NATURE OF WORK ��ct�.�ii��'-c?S �u b�o�k a ur �C2c�� J �w y � � l2 l�q��.SS 1 vt��r�a,�+�� c�n,QQ 2 --3c� o ,�. n bi�� !es SURFACE TO BE DISTURBED (Check Appropriate Boxes) j7 {� y�i ❑Roadway ❑Shoulder ❑Concrete ❑Bituminous ❑Gravel (�furf Only ��nr�r 1� �� 1��`-`�- r�� 5 �' ❑Other(explain) 'Y27W�-� CYad� 30Z) `�"U'^ �� Gr �� DEPTA OF EXCAVATION BELOW NUMBER&SIZE OF E CAVA NS METHOD OF INS ALLA ON/CONS CTION su�ACE � � �.�� -k �K'� - -(�.a� he�.e c�c,�e r �'�-r�e s�u� WORK TO START ON OR AFTER WORK TO BE COMPLETED BY IS TRAFFIC DETOUR NECESSARY? Yes No t./C/1�'��r �� til'6�`D�I� 1�t• YES,TRAFFIC CONTROL PLAN IS REQUIRED.) APPLICANT'S ACCEPTANCE,WAIVER AND INDEMIVIFICATION T6e undersigned applicant hereby agrees to comply with applicable statutes,rules,and the standard conditions and special provisions of this permit.The appiicant understands and agrees that no work in connecHon with t6is application will be atarted until t6e appl3calloe has been approved and the permit isaued. The applicant is aware of circumstauces or 6azards that may arfse w6ile performing the work associated with t6is applica8on that could result in injury,loss,damage or deat6,and the applicsnt assumes the risk of such circumstances,dangers and hazards,whether reasonably foreseeable or no� The applicant also understands that this permit may also be subject to t6e approval of local road suthorities having joint aupervision over said sheet or highway,and msy be subject to applicant's compliance with the rules and regulations of the Minnesota Enviroomental Quality Board and/or any other affected governmental agencies. The undersigned applicant e�►ressly agrees that escept for negligent acts of the State,its agents and employees,t6e applicant or his/her sgenta or watractor shsll assume all Ilabllity for,and save the State,ita sgents and employees,harmless from any and all clsims for damsgea,aclions or causes of acHon arfsing out of the work to be done in connection with this appllcaHon aod permit NAME ITLE EMAIL ADDRESS ' ff<`�' S i�� c�c�.,�s) v�z . Ca 1liK s�-G�t �,., DATE (�� ( SIGNATURE �f r�k� DO NOT lf'RITE BELOW THIS LINE PERMIT NOT VALID UNLESS BEARING AUTKORIZED MnDOT SIGNATURE AND PERMIT NUMBER AUTHORIZATION OF PERNIIT It is eapressly understood that t6is permit is wndiNoned upoa restoraHon of the trunk dighway right-of-way to its original condiHon or to s satisfactory conditlon. In consideration of the applicant's agreement to comply in all respects wlth the applicable laws and the conditions of the Commissioner of Tranaportatlon pertafning to titis permit,permission is hereby granted for the work to be performed as described in t6e above application,said work to be performed in accordance with the followln�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 DISTRIBIITION DEPOSIT REQUIREMENTS DEPOSIT 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# Roadwe Re latiOns SU ervisoi Deposlt to be returned upon saNsfactory completlon ojaU work Bond# DATE WORK COMPLETED The date when the work is com leted must be re oned to the MnDOT District PermiJs O ice Paee 1 of 2