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HomeMy WebLinkAboutLakeside Ave ROW Permit _ � �,�(���� Au� 1 5 zoos E PERMIT TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS AND APPLICATION FOR INSTALLATION OF UTILITIES 1. Location LAK�SII�E f,U'L� 2. Nature of Work `�+�Ly 'g'F'`�D S,E iCV l e.E. CA$LL. 3. Tndicate below items to be afFecred and include a sketch ar plan of work to be done. Curb & Gutter Street Surface TraillSidewalk Trees: Pond/Wetlands (Publically owned Traffic Control Devices/Signs or Privately owned _) Drainage Utilities StructureBuildings pther $L!/D . ^ 4. Method of Installation or Construction CA�SLf �LOC.�I �- , SD�fi:: - ,�� �^ • hi 5. Work to start on or after: 8 " Z$'� and shall be compteted by: �� A y unless an extension granted to: by: j DATE STAFF/DATE ' 6. Will detouring of traffic be necessary? 1`10 If necessary to detour traffic, describe suggested route: 7. Provide with this application a copy of the contractors Public Liability Insurance. DETOURS: The Director of PubJrc V�p�s,s�sha�l,�e �qtti�ed �;wr@ting at least 72 hours in advance of any detour being established, ct►anged or discontinued. NAME OF APPLICANT =N ����R ��-L�C�.� ���.. PHONE RSZ-`�'�'����'' PLEASE PR1NT FAX q 52 - 22.1e - 3 7 5 E3 ADDRESS '�`�a ����� St. S,E. PI�1QR. LAK�. MN 553'7Z- AZ.9�t STREET CITY STATE ZIP NAME OF PARTY OR ORGANIZATION PERFORMING WORK CONTACT PERSON: mN 8 ARLFIGE.. EMERGENCY (24 HR.) PHONE #: � � 2 9� g ' S 8 8� ADDRESS DAY PHONE Q52- 22(0 - 7fl1A4 STREET CITY STATE ZIP _ The rsig rewith accepts the terms and conditions of this permit by the City of Prior Lake as herein contain d agree lly comply therewith to the satisfaction of the City of Prior Lake. Signe . 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