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Check one: Multiple Trip; Valid from effective date to expiration date (Not to exceed 12 months) Seasonal; Exempting essential commodity haulers when County spring road weight restrictions are in effect. Vehicle License No. : Route of Move: From: Anticipated Number of trips: Freight or Commodity to be hauled: Allowable Legal Gross Vehicle Weight: Description of Truck (i.e. axle configuration): Allowable Gross Vehicle Weight: Special Conditions, Route to be used, or Terms: Permit Effective Date: Permit Expiration Date: Applicant Signature Date Date This permit is valid only for the weight and/or load size stipulated in this permit. This permit is valid only for the time and date stipulated in this permit. This permit is valid only for the number of trips stipulated in this permit. This permit is valid only for the vehicle listed on this permit or attached list if more than one. This permit is valid only for the route designated in this permit. Any violations of the requirements stated on this permit will be cause for immediate revocation of said permit. no liability for incorrect or false information provided on this application by the permitee. (Permit Required for Each Power Unit and Must be Carried in the Truck Cab) Fax No: Acceptance of Conditions: I, the applicant, have read and fully understand the requirements and conditions of this permit, and if granted a permit, I will comply with the terms and conditions which apply. Douglas County assumes (N/A if unknown) To: DOUGLAS COUNTY HIGHWAY DEPARTMENT Multiple/Annual/Seasonal Trip Permit Application Raw Forest Products, Overweight Equipment, etc… Insurance Company Name: Desired Expiration Date: Desired Effective Date: Return this completed form by mail, fax or email to the Douglas County Highway Department, P.O. Box 174, Hawthorne, WI 54842 Phone (715) 374-2575, Fax (715) 374-2495 or e-mail: [EMAIL REDACTED] County Representative Signature Telephone No. : Applicant Name: Address: City, State, Zip: Address: Douglas County Highway use only City, State, Zip: Last Updated On: 1/17/2011 SIGN