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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. 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