Trip Permit - Clark County, Washington



|[pic] |Clark County Public Works |County Permit |Trip Permit | |

| |4700 NE 78th Street |City of Van. Permit |30-Day Permit | |

| |Vancouver, WA 98665 |County & City Permits |Annual Permit | |

| |Phone: (564) 397-2434 | |Manufactured Home | |

| |Fax: (564) 397-6106 |Same Day Return Trip | |

| |Email: PWOverlegal@clark. | | |

|OVERSIZE/OVERWEIGHT VEHICLE PERMIT APPLICATION |

| |

|NAME: |      |ADDRESS: |      |

|CITY: |      |ST: |      |ZIP: |      |

|DESCRIPTION OF LOAD OR VEHICLE: |      |

| |

|ORIGIN: |I-5 @ LaCenter MM 16 |DESTINATION: |I-5 @ Woodland MM 21 |

|ROUTE: |Exit #16 off I-5 east to NW LaCenter Rd to NW Pacific Hwy to NW Hayes Rd @ Bridge 80 enter Cowlitz County |

|***APPROVAL FROM COWLITZ COUNTY IS REQUIRED 360.577.3030 EXT. 2527*** |

|GROSS WEIGHT: |      |OVERALL WIDTH: |      |OVERAL|

| | | | |L |

| | | | |HEIGHT|

| | | | |: |

|TRACTOR AXLES: |

|STATE OVERLEGAL PERMIT # |      |STATE TRIP PERMIT # |      |

| | | | | |

|PERMIT START DATE: |      | | | |

|READ THIS BEFORE SIGNING: This combined application/permit issued in accordance with R.C.W. 46.44.090 with the specific understanding that all applicable Washington |

|State, County, and City Laws, Administrative Codes, Regulations and Conditions, including those not listed hereon will be complied with. I, the undersigned permittee |

|or agent thereof, certify that the information shown herein is known by me and is true and correct and understand that the permittee shall be liable as set forth in |

|R.C.W. 46.44.110 for all damages to any public highway, bridge or elevated structure resulting from the movement of equipment authorized by his permit on the public |

|highways of this state. The permittee shall further hold blameless and harmless and indemnify the county, its officers, agents and employees against any accident, |

|liability, loss, injury, action and the costs thereof arising from the conduct or operations of the permittee in connection with this permit. I further understand |

|that prior to movement the permittee shall establish a routing to safely detour all structures having a limited clearance less than the permitted height. |

|SIGNED: | |DATE: |      |

| |Permittee/Agent Thereof | |

| |

|CREDIT CARD NUMBER IS REQUIRED: |     |     |     |     |EXPIRATION: |      |

|****FOR OFFICE USE ONLY**** |

|Comments/Requirements: |      | |

| | | | | |

|****NOT VALID WITHOUT STATE PERMIT**** This permit must be carried on the above described vehicle. Permit subject to cancellation if state/county/city requirements |

|are violated. |

| | |      | |Manual Approval: | |

|Clark County Public Works Signature | |Date | | |Initials |

Northbound Bridge 80 Detour Check One: Check One:

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