HomeMy WebLinkAboutArcadia Ave & Dakota St ROW Permit � ' JOB #t O(o -055P
EXHIBIT "C"
PERMIT
TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EA�EMENTS
AND
APPLICATION FOR INSTALLATION OF UTILITIES
1. Location A ftGAD SA i9UE S. £. 4 DAXTJTi� �9L� �S.E
2. Nature of Work PLA�£ NELI/ CABZE FDR /'DLI�� STATIDAf AND RFPLA�� A
S� G'TION �F L- XIS�I�I/G �ABL�'
�. Tndicate b�low items to b� affecr�d and ir.clude zsket�h cr nlan of work to be done.
. . , ,.,. _ .
Curb & Gutter . Street Surface
TraiVSidewalk � ' Trees:
Pond/Wetlands (Publically owned
Traffic Control Devices/Signs or Privately owned _)
Drainage Utilities
StructureBuildings Other '
4. Method of Installation or Construction DI�C �If�NAL BfJRL RND dPF_N TRENGH
5. Work to start on or after: �'�`�� and shall be completed by: 1 U/EEK unless an extension
granted to: by:
� , DATE STAFF/DATE
6. Will detouring of traffic be necessary? ND If necessary to detour traffic, describe suggested
route:
7. Provide with this application a copy of the contractors Public Liabiliry Insurance.
DETOURS: The Director of Public Works shall be notified in writine at least 72 hours in advance of
any detour being established, changed or discontinued.
NAME OF APPLICANT =N ����� ��-�-��� ���-- PHONE ° �SZ - `� 7-375 E?�
PLEASE PRINT FAX q52- 22.l0 - 3754
ADDRESS �`�� ��R�t�D St. S�E, PR1pR. 1.AKfr,._ MN 553�Z - AZ 9 �t
STREET CITY STATE ZIP
NAME OF PARTY OR ORGANIZATION PERFORMING WORK
CONTACT PERSON: �� aAR�v�- EMERGENCY (24 HR.) PHONE #: �� Z- 91 g - S 8�3l
ADDRESS DAY PHONE q52-' z2(o - ��(�4
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 fuily comply therewith to the satisfaction of the City of Prior Lake.
Signed: �G� �rm��- Title; ����NEE� Date: 3`3D - 06 _
79
�XHIBrT "C"
FOR CITY USE ONLY AUTHORIZATION OF PERMIT
FiNANCIAL SECURITY: AMOUNT: TYPE:
(Cash, bond, LOC etc.)
Fee: $ �d'� Receipt No. � ?ermit No. U-�O�o.- �
LIABILITY INSURANCE PROVIDED: ��'4'{� /'���`�-�✓�
In consideration of agreement to comply in all respects with the regulations of ttie 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 applicltion, said work to be done in accordance with special provisions as
hereby stated: .
APPROVED BY: DEPT. OP PUT3LIC WORKS
, By: �7 f —,T �'� —
� IDATE
ALL LEGAL REQUIREMENTS SHOWN ON PAGE ONE (1) AND ON ALL "SPECIAL PROVISIONS" SHALL
�3E CUMPLiED WITH. THE DATE WHEN WORK 1S COMFf.ETEB i�1�;ST �E REPORTED TQ THE CITY
OF PRIOR LAKfi C?TY ENGINEER.
80
N140294
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