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DRIVEWAY PERMIT APPLICATION
PERMIT # CJ5" - D /0
DATE: ?I.z- ~ ?J~_. .,.
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\1 \1\ SEP 2 9 Z005
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OWNER NAME:
PROPERTY ADDRESS:
Sr N.e,
DRIVE APPROACH
TO CONSTRUCT: D New ~epIace 0 Widen
Approved BY.
wide (TEMPORARY, PERMANENT) Drive approach
Date: It!) -L(..t)S'
FJ/fJ.
Type of Material & AlC-.R"t!" ,......e
REQUIREMENTS
1. No work under this apptication is to be started untY application is approved and the permit is issued.
2. Where work on traveled roadway is necessary, traffic must. be protected and flags, signs, safety cones and proper
barricades must be placed in accordance with safety procedures.
3. No foreign material such as dirt, gravel. or bituminous material shan be left or deposited on the road during the
oonstructlon of driveway.
4. Road must be swept clean after work is completed.
5. Prior to placement of ooncrete or bitumInouS surfacing, the applicant shall notify the Engineering Department that the
work has been completed and is ready for fmal inspection.
6. No changes or alterations in entrances may be made at any time without written oennission from the Engineering
Department or inspector.
IMPORTANT: Before startina work...
The Applicant shall call Gopher State One Call (1-800-252-1166) 48 hours prior to starting work. Applicant must caD the
Engineeri Department (952) 447-9830 for Inspection 24 hours prior to time of ins .
When widening or constructing new driveway approaches a $10.00 fee Is required at the time of application and a sketch of the
property depleting present and proposed driveways in relation to the property line.
(Sketch on reverse side of application or provide a separate plan)
As provide in Ordinance NumberS 1107.205 & 1107.206> I, We the undersigned, herewith make application
for permission to construct the drtveW&y at the above location, said driveway to be constructed to conform
\Nith the standards of the City of Prior Lake and to 9Il'/ special provisIonS Included in the permit. It is agreed
that aU work will be done to the satisfaction of the Engineering Department. It is further agreed ttlat no work
in oonnection with this application will be started until the application. pproved and permit issued.
fJ-5fAJtt.,T f 84"~~ Au'llf~A ~
Contractor I
1\ nt's Signaiure
7/2 J</t? S-
Date:
ASPHALT & CONCRETE BUY KNOX INC.
Details Yes No 0. rll/() 1'. I ('
Om Cross Street -UlLJA. ( IV J
Cable W ~
Drainage Probl DO! + +- ;t/
Electnc Wires
Gas Line 0 - 7
Grade Change 0 (iJ
D~
Heaving
Overhead Wires 0 ~
Phone Wires 0 B
Roof Overhang 0 [tJ
~ Saw cut at street \'e'
Sprinkler SystemO 5a
TreeUmbs om
Tree Roots 0 m
Tree SturT'4lS 0 1tI
Water Shut-off 0
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Prop. Dist.
AP GR(ffij)SW SP PT SD FT
Ale: 10yr 5yr Partial OIL WL
% EXC~VATE $ ,~.~ .
BASE . ~ ~ ~ .
IL E/B 3/5" ~ ~~~
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TRUCKS
IN/OUT
CLAY
BARRIER
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REPLACE
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Approval: #
Existing
SPECIAL INSTRUCTIONS
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Regarding this Installation is everything you wanted in writing? Customer has received Instrucion booklet. 0\ ~stomer agrees to pa reqUired p'3r1ll1t e Y~fJ Q.-.NO
""0<. ,,,..,,",,,," W""",. '." '""''',' DO IT RIGHT ".THE FIRST ~...BUY KNOX ~ ~