HomeMy WebLinkAbout15310, 15296, 15286 Edgewater Cir ROW Permit . <
EXHIBIT "C"
�QB#� U(�-031 �
PERMIT
TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS
AND
APPLICATION FOR INSTALLATION OF UTILITIES
1. Location I 5310 , ISZ9(o , tS ZBIo EDGEWAT�.P` CIR .
2. Nature of Work R�PU4CE BURIE� PHONC SEILVICE UNES 'CO R�.LE�VE EXHAUS�D
MhIN LtNE CA81�E. 1N Rf�A OF '�P..OSE�i :
3, ., .below items to be affecxed and include a sketch ar plan of work to be done.
Curb & Gu#ter , Street Surface
TraiUSidewalk ' Trees:
Pond/Wetlands (Publically owned
Traffic Control Devices/Signs or Privately owned _�
Drainage Utilities
StructureBuildings Other X 8LV D. `
4. Method of Installation or Construction C�AEt..E �'LOW AI'1� BOT.E. "
5. Work to start on or after: 7 ' Z'`�-' - �band shall be completed by: Z- �yS unless an extension
granted to• by:
DATE STAFF/DATE
6. Will detouring of traffic be necessary? !�L � 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 Public Works shall be 1lotified in writing at least 72 hours in advance of
any detour being established, changed or discontinued.
NAME OF APPLICANT =��E.C��R T�L��� �1�'� PHONE `�SZ
PLEASE PRINT FAX q 52- 2Zlo - 3 7 5 a
ADDRESS '�`�Q ��Ri�'hD St. S�E� �R10R LALZT�. MN 5537Z- AZ-°I`�
STREET CITY STATE ZIP
NAME OF PARTY OR ORGANIZATION PERFORMING WORK
CONTACT PERSON: �� $RR-���- EMERGENCY (24 HR.) PHONE #: �� 2- 9 � g " 5 8 a'1
ADDRESS DAY PHONE q52- 22Io - 7O(o4
STREET CITY STATE ZIP _
The undersigned herewith accepts the terms and conditions of this permit by the City of Prior Lake as herein
contained and agree to fully comply therewith to the satisfaction of the City of Prior Lake.
Signed: ,�i� Title: �t�l L�1 N EER.. Date: "T - I 6 �
79
+ �
�XHIBIT "C"
FOR CITY USE ONLY AUTHORIZATION QC PERMIT
FINANCIAL SECURITY: AMOUNT: �1'PE�
(Cash, bond, LOC etc.)
Fee: $ � Receipt No.
�! ?ermit No. "a' t
LIABILITY INSURANCE PROVIDED: B/'4��/U� �����''�
In consideration of agreement to comply in all respects with the regulations of the City of Prior Lake covering such
operations, and pursuant to authorization duly given by said City of Prior Lake; permission is hereby granted for the
work to be done as described in the above npplication, said work to be done in accordance with special provisions as
hereby stated: ,
r .
� APPROVED BY: DEPT. OF PUBLIC WORKS
' By . � � 7 �8-0�
� /DATE
ALL LEGAL REQUIREMENTS SHOWN ON PAGE ONE (1) AND ON ALL "SPECIAL PROVISIONS" SHALL
BE COMPLIED WITH. THE DATE WHEN WORK IS COMPLETED MUST BE REPORTED TO THE CITY
OF PRIOR LAK6 C1TY ENGMEER.
80
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