HomeMy WebLinkAboutIndustrial Lane ROW Permit �� � � SOB �Oln-O[o4P
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APR 2 1 20i;o
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PERMIT
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TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS
AND
APPLICATION FOR INSTALLATION OF UTILITIES
1. Location INDUSTR1Al. LN, p D'E.�.(Z.�IEL� INDl1STRlAL P�tRK."
2. Nature of Work �.��E� OF COPPER P}{OWE G4Bl.ES AP.1� PLASTIC CONDU IT' It�1 SO11JT
TR�NCk! W 1TN MV�.C.. POW'E.f` AND 4A5.
�. in�icate below items to be affec�ed and ir.clude a sket�h cr nlan of work to be done.
Curb & Gutter Street 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 .B�C,kI-tOE. -SDINT 'CR�'JJGN "
5. Work to start on or after: 5 S� b(o and shall be completed by: � D�'y unless an extension
granted to: by:
. . ,
DATE � . STAFF/DATE
6. Will detouring of traffic be necessary? n1� 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 notified in writing at least 72 hours in advance of
any detour being estabiished, changed or discontinued.
NAME OF APPLICANT = N����-� T�-�- ��-� ��-- PHONE RS Z-`��'375E?a
PLEASE PRINT FAX 952- 2Z(o - 375a
ADDRESS `�`� ���R st. 5�� � Pl�►AR. LA1Z� M N 5 S3� Z - A Z.°15
STREET CITY STATE ZIP
NAME OF PARTY OR ORGANIZATION PERFORMING WORK
CONTACT PERSON: �N aA��v�- EMERGENCY (24 HR.) PHONE #: �� 2 9� g ' S 8 S �
ADDRESS DAY PHONE q52-22Lo -'7flfi.+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 ' ed ee to fully comply therewith to the satisfaction of the City of Prior Lake.
Signe . Title: �� 81 N�` E� Date: 9 ' ' 2 �"' 0 �O
79
.- ,
�XHIBIT "C"
, '
FOR CITY USE ONLY AUTHORIZATION DI' PERMIT
FINANCIAL SECURITY: AMOUNT: TYPE:
(Cash, bond, LOC etc.)
Fee: $ �t�b�e Receipt No. �_ ?�rmit No. —�jr•��
LIABILITY INSURANCE PROVIDED: Qr'�+r�� I����G �v�
In consideration of agreement to compiy in ali respects with the regulations of the City of Prior Lake covering such
operations, and pursuant to luthorization duly given by said City of Prior Lake; permission is hereby granted for the
work to be done as described in tlie above lpplication, said work to be done in accordance with special provisions as
hereby stated: .
,
APPROVED BY: DEPT. OC PUIILIC W02KS
, By: s /-06
' lDATE
ALL LEGAL REQUIREMENTS SHOWN ON PAGE ONE (I) AND ON ALL "SPEC[AL PROVISIONS" SHALL
BE COMPLIED WITH. THE DATE WHEN WOIZK IS COMPLETED MUST BE REPORTED TO THE CITY
OF PRIOR LAK� C?TY ENGiNEER.
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