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<br />fORM 8S0-040-1 ~ <br />SYSTEMS PLA.>.JNING - 11/94 <br />PAGE 15 u(6 <br /> <br />....---------_.__.~--- .--.--.--------.------------------------ <br /> <br />s- <br />-S- <br />._~JPs_- <br /> <br />_____ _____ __ ArI'LICANT (C......,,") <br />PART 10: ADDrrIONA~JNrOflMA TION wlllcn MA l! BE R.EQUESTED <br /> <br />Numberofpackq~. <br /> <br />Applic:aUon forms bearing original silllatun:s. <br /> <br />Arplicable de5;gn~ end I1?Jlr.: 5TUdin U1d !ealed by 8 pmfeMinnlll tngineer_ <br /> <br />NOTES: <br /> <br />PART II: NOTICE TO APPLICANT - -j. <br /> <br />Proposed li::uure, in lhe ri&JIl-9f-wIY. suc:h as median openings..d olher traII'K: control devices, life not put of tile oonncctionfs) to be authori1bJ by a <br />conncl."tion permil The Oepu1mcn, ~s the rish' to cIIMF Ihese relllures In the fUture in order to pror:lOte safety in tJ1e rir.hl of way or efficient <br />trOlJlic uper.Jtions on the highway Expenditure by the eppllc:.ant ormonie! lOr InstaJlation Of mo.intenUlcc of such reafU~S .hall ~t no vested right in <br />the mlUl1tenan~ o(such fralUl'CS. <br /> <br />PART 11: CERTIFICATION ND SIGNATURE <br /> <br />I certJ().lI;at I am familiar w. <br />complete and 1J(("UA(e <br /> <br /> <br />signedL <br /> <br /> <br />information contained in this Ippllcatioo and 1h0l to the best ofm)' knowledge and belief slJch iaformntion i.s ll'Ue, <br /> <br />Date: <br /> <br />t4...........~~~.t <br /> <br />Printed Name: I' <br />rnLE:/ <br /> <br />,~ll)oIAL Ot<:NrEA 1l101$TUnu- 'f\MNIl1lf AmxAIIU!I. <br /> <br />c........ A.....J <br /> <br />W'f!<' <br /> <br />-. <br /> <br />... <br /> <br />END <br />