HomeMy WebLinkAboutFremont Avenue ROW Permit . ,
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SOb # OG-O�Z P
EXHIBIT "C"
PERMIT
, TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS ,
AND
APPLICATION FOR INSTALLATION OF UTILITIES
1. Location FREl�'10N7" /�UL- /1/L/l
2. Nature of Work PLH�E IYEI// COPPER HIVD FIBFR CA�BLES BLf.ILD ELEGTROALTCS SI7�
�. Tndicate below items to be affecred and ir.clude a �!z�tch cr plan of work to be done. ,
v. �, � .
Curb & G,utter Street Surface
TraiUSidewalk' � � ` � ' Trees:
Pond/Wetlands (Publically owned
Traffic Control Devices/Signs or Privately owned _�
Drainage Utilities
StructureBuildings Other `
4. Method of Installation or Construction G)PeeN TR�JI/CH AND BDRE "
5. Work to start on or after: �`��`/�� and shall be completed by: 3 ��E��f unless an extension
aranted to: by:
, � STAFF/DATE
6. Will detouring of tra�c be necessary? �'� 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 ho�rs in advance of
any detour being established, changed or discontinued.
. NAME OF APPLICANT = N�� ���� TE- ��-- PHONE a
PLEASE PRINT FAX �52- 22.(0 - 375f�
ADDRESS 41o�iD CDLGRi40D S.t. S�E, PR1QR.. LRIZ� M N 5$3'7 Z- A Z.9�t
STREET CITY STATE ZIP
NAME OF PARTY OR ORGANIZATION PERFORMING WORK
CONTACT PERSON: �� aRR-�G'�- EMERGENCY (24 HR.) PHONE #: �� Z' ° r �°� ` 5 a� 7
ADDRESS DAY PHONE q52' ZZ1v ' 7flk'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 fully comply therewith to the satisfaction of the City of Prior Lake.
Signed: � 4i�` %�i Tr/h�--- Title: ���'� N EE� Date: 3- Z 7-L��i
79
� s
�XHIBIT "C"
FOR CITY USE ONLY AUTHORIZATION OP PERMIT
FINANCiAL SECURITY: AMOUNT: TYPE:
(Cash, bond, LOC etc.)
Fee: $ ��d•�� Receipt No. I 7� � ?ermit No. �Q��
LIABILITY INSURANCE PROVIDED: ��'4�R� ���(��
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 tl�e above lpplication, said work to be done in accordance with special provisions as
hereby stated: ,
APPROVED BY: DEPT. OF PUBLIC WORKS
g � �— ��
/DATE
ALL LEGAL REQUIREMENTS SHOWN ON PAGE ONE (1) AND ON ALL "SPECIAL PROVISIONS" SHALL
$E t;OMPLIEG WiTH. THE DATE WHEN 1%✓u2K IS COMPLr,TEI3 NiJ�T Bc RtPORTED TC TEi� CITY
OF PRIOR LAK6 C!TY ENGINEER.
80
MINNE40'r.6:.UE1'N1NI GIdh1Y
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