HomeMy WebLinkAbout17073 Adelmann St & 16776 Fish Point Rd ROW Permit FEB � ?_006
E_ XHIBIT �C��
� ._ ...__. ...._.__..��..n —
PERMIT '
, TO WORK WITHIN CITY PROPERTY/�2IGHT-OF-WAY/EASEMENTS .
AND
APPLICATION FOR INSTALLATION OF UTILITIES
1. Location f 70 73 f3 DFL A719N/U ST S.L� ,� �� 7 7G FISId PdIN KD ,f. E
2. Nature of Work pt/�CE FI86R I"NTD /79fJZ'NTEN/�NCE BUILDINb � J�TI?F HRtL
;. , Tn�,icrpte ; below items to be affecred and ir.clude a ��etch cr plsn of work to be done.
Curb & Gutter x, ;.�� Street Surface
;. r '
TraiUSidewalk Trees:
Pond/Wetlands (Publicatly owned
Tra�c Control Devices/Signs or Privately owned _)
Drainage Utilities
StructureBuildings Other `
4. Method of Installation or Construction �3�cK13D� d- PuLi, THRL[ FXf.STINIs �'JU GT
5. Work to start on or after: y' � �'D6 and shall be completed by: � Df� yS 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 Liability 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 T� G�,R TE.L��.� � ��V�... PHONE qSZ
PLEASE PRINT FAX 952- ZZLo - 375f�
ADDRESS ��p ��R140G 5t. S�lE � PR1t�R.. l.A{Zf� M N 553'7 Z- C� Z°1�t
STREET CITY STATE ZIP
NAME OF PARTY OR ORGANIZATION PERFORMING WORK TTRDLR �- 1fSGh'STRO/I�
CONTACT PERSON: �� $AR�G'�- EMERGENCY (24 HR.) PHONE #: �� Z' 91 °I - 5 8 4 �
ADDRESS DAY PHONE q52' 22(0 - 7flGs4
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: �ur'� T�s�-osn Title: ��B�NFER-- Date: 2-IO-D(-,
79
EYHIBIT "C"
FOR C1TY USE ONLY AUTHORIZATION OP P�RMIT
FINANCIAL SECURITY: AMOUNT: TYPE:
(Casfi, bond, LOC etc.)
Fee: $ '� Receipt No. ?ermit No. _��� �Z
LIABILITY INSURANCE PROVIDED: ��af�� ����Gw''�
In consideration of agreement to compiy 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 lpplication, said work to be done in accordance with speciai provisions as
hereby stated: ,
APPROVED BY: DEPT. OP PUIIL[C W02KS
� BY: i�� �,/- 7-06
/DATE
ALL LEGAL REQUIREMENTS SHOWN ON PAGE ONE (1) AND ON ALL "SPECIAL PROVISIONS" SHALL
B� COMPLiED WiTi-I. T�iE DATE 'vV'riEiv W�RK iS COMPLETED Iv1UST B� REPORTED TO THE CITY
OP PRIOR LAKE C1TY ENGINEER. .
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