HomeMy WebLinkAbout16045 St. Paul Ave ROW Permit ` SD� � 28Z$
EXHIBIT "C"
PERMIT
TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS
AND
APPLICATION FOR INSTALLATION OF UTILITIES
1. Location I[c0�-S ST. pAUL AV'�. S.E.. - N�W HOVi�.
2. Nature of Work ���-�- F-XIST1NGe �1JP�1�D S'Ei�.VICE L1NE TO IbOZI ST: PAUL. AVE.S�
3, indicat� below items to be, affecred and ir.clude a sket�h cr olsn of work to be dane.
Curb & Gutter Street Surface
TraiUSidewalk Trees:
Pond/Wetlands (Publically owned
Traffic Control Devices/Signs or Privately owned _�
Drainage Utilities
StructureBuildings Other X BLV D. `
4. Method of Installation or Construction �$� ��-DW
5. Work to start on or after: 7 ' Z�" d� and shall be completed by: � pA� uniess an extension
granted to: by:
DATE STAFF/DATE
6. Will detouring of tra�c be necessary? N(� If necessary to detour traffic, describe suggested
route:
7. Provide with this application a copy of the contractors Public Liability Insurance.
DETOURS: 7fie Director of Public Works shall be notified in writipE at (east 72 hours in advance of
any detour being established, changed or discontinued.
NAME OF APPLICANT = N� E��� ��l- ��� ��'�- PHONE `�S Z
PLEASE PRINT FAX q52- 22.l0 - 375i�s
ADDRESS '�+`�D CQtORIArbC� 5t. S,IE, fi'RIUK. l.A{Z'E,_ MN 5S'S7 Z- AZ.
STREET CITY STATE ZIP
NAME OF PARTY OR ORGANIZATION PERFORMING WORK
CONTACT PERSON: �N $AR��'� EMERGENCY (24 HR.) PHONE #: �� Z' °� �°� ' S 8 8 �
� ADDRESS DAY PHONE q52- 2210 �'7fl(Q4
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.
Si ned: �.�aCr � r 2��u1�' Title: ���° ���E� Date: �' �" ��
g
79
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�XHIBIT "C"
FOR CITY USE ONLY AUTHORIZATION OP �'ERMIT
FMANCTAL SECURITY; AMOUNT:_ - TYPE:
(Cash, bond, LOC etc.)
Fee: $ Receipt No. ?ermit No.
LIABILITY INSURANCE PROV[DED:
(n consideration of agreement to comply in alf 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 application, said work to be done in accordance with special provisions as
hereby stated: .
APPROVED BY: DEPT. Or PUIIL[C WORKS
By:
/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 LAKE CITY ENGTNEER.
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