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HomeMy WebLinkAboutElm Ave & Basswood Cir ROW Permit ° • EXHIBIT "C" PERMIT �'Y� � �[o -OZO P TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENT$ AND APPLICATION FOR INSTALLATION OF UTILITIES 1. Location INTEICSECT1D1�1 f!T EL1�1 AYE. AND B/�SSWVOD C.11C. 2. Nature ofWork RE�A1R k1JD OR ICE�IACE �A1LIl�lfr S�.CT10N OF EXISTItJG G4b1� . �. Tndicate below items to be affecred and ir.clude a sketch ar plan of work to be done. Curb & Gutter Sri Surface TraiUSidewalk Trees: Pond/Wetlands (Publically owned Traffic Control Devices/Signs or Privately owned � Drainage Utilities StructureBuildings Other X BLVD. ` 4. Method of Installation or Construction 'BACKHOE �tND 'BO PS. " 5. Work to start on or after: �' �"�� and shall be completed by: � Da`� unless an extension granted to: by: DATE STAFF/DATE 6. Will detouring of traffic be necessary? N� 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 writing at least 72 hours in advance of any detour being established, changed or discontinued. NAME OF APPLICANT Z N T C. Ca�.�. �TE.L �C�.0 ���... PHONE °� S Z- �7-37 SE?� PLEASE PRINT FAX 9 52 - 22.10 - 3 7 5�a ADDRESS '`�`�O CdLDRi��D s�t. S�E., Pt�lt�i� l.A4Zg.. M N 5 S'S� 2. - A Z.9� STREET CITY STATE ZIP NAME OF PARTY OR ORGANIZATION PERFORMING WORK CONTACT PERSON: �N $A���'�- EMERGENCY (24 HR.) PHONE #: �� 2 9 � q ` S P 8l ADDRESS DAY PHONE q5 z21° - 7fl1�'4 STREET CITY STATE ZIP - The undersigned herewith accepts the terms and conditions of this permit by the City of Prior Lake as herein con n gre Ily com ly therewith to the satisfaction of the City of Prior Lake. Sign rtle: F-�B�NEE� Date: 6 O� 79 � , �XHIBIT "C" FOR CITY USE ONLY - �- AUTHORIZATION Of PERMIT . FINANCIAL S�CURITY: AMOU�IT: TYPE: � � � � (Cash, bond, LOC etc.) Fee: $ �� Receipt No. "'—'" ?ermit No. v � L LIABILITY INSURANCE PROVIDED: �y��'� �� ` ''� 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 lpptication, said work to be done in accordance with special provisions as hereby stated: . APPROVED BY: DEPT. OF PUBLIC WORKS � BY: �� 7- 7 0,6 ' /DATE ALL LEGAL REQUIREMENTS SHOWN ON PAGE ONE (1) AND ON ALL "SPECIAL PROVISIONS" SHALL BE CCMPLIED WiT'H. 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