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Home My WebLink About16691 & 16731 Highway 13 (2) � � O � PRIp� !: � C� �5�� PERMIT PERMIT TO WORK WITHIN CITY PROPERTY RIGHT-OF-WAY/EASEMENTS AND APPLICATION FOR INSTALLATIOPI OF UTILITIES 1. Location � n �o� � � � � '7 � � � r�`' y � � 2. Nature of Work 1�� l G�1' l O►�1 3. Indicate below items to be affected and include a sketch or plan of work to be done. � Curb & Gutter Street � TraiUSidewalk Trees: Pond/Wetlands (Publically owned Traffic Control Devices/Signs Or Privately owned ) Drainage Utilities StructureBuildings Other 4. Method of Installation or Construction 91 f,- F� 'w ��' TA�'P �+- P`^ �-L- �^'� ��'�[r P� �L G 2 5. Work to start on or after: 7- 2� and shall be completed by: 7� unless an extension granted to: by: DATE ST.4FF/DATE 6. Will detouring of traffic be necessary? N O 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 established, changed or discontinued. � NAME OF APPLICANT � L F�'r� ��$S1 �J i� �" PHONE C� i 2 3(og 3 vu 1 PLEASE PR[NT AnDxESS �t D� � w i� DS c12 CT S/'�.! �(�t'� M N 5�.3 7 � STREET C1TY STATE ZIP NAME OF PARTY OR ORGANIZATION PERFORMING WORK � �.��5�'fl� �-+*w"' �� CONTACT PERSON: J� +... K� �' � EMERGENCY (24 HR.) PHONE#: �� i � 3 t�9 3� � l ADDRESS: �� r ��5�2 c r S��G t� � S37�AY PHONE �/ 2 3�R 3�i STREET CITY STATE ZIP The undersigned herewith accepts the terms and conditions of this pe►mit by the City of Prior Lake as herein contained and agree to fully comply therewith to the sa � tion of the City of Prior Lake. Signed: '__„_ Title: V' C� T r�t� S� dlsN +' Date: 7` � 7" v� EXHIBIT "C" TO PRIOR LAKE PUBLIC WORKS DESIGN MANUAL PERMIT TO WORK WITHIN CITY PROPERTY RIGHT-OF-WAY/EASEMENTS AND APPLICATION FOR INSTALLATION OF UTILITIES PAGE 2 FOR CITY USE ONLY AUTHORIZATION OF PERMIT FINANCIAL SECURITY: AMOUNT: TYPE: (Cash, Bond, LOC, Etc.) Fee: $ � — Receipt No. Permit No. U1' ' G � V � LIABIILITY INSURANCE PROVIDED: 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 application, said work to be done in accordance with special provisions as hereby stated: APPROVED BY: DEPT. OF PUBLIC WORKS By: _�� 7 � 7 0 � /DATE ALL LEGAL REQUIREMENTS SHOWN ON PAGE ONE (1) AND ON ALL "SPECIAL PROVISIONS" SHALL BE COMPLIED WITH. THE DATE WHEN WORK IS COMPLETED MUST BE REPORTED TO THE CITY OF PRIOR LAKE CITY ENGINEER. G:�PERMITSUtOW_Utility�ROW RERMITS.doc EXHIBIT "C" TO PRIOR LAKE PUBLIC WORKS DESIGN MANUAL REGULATIONS PERTAINING TO THE INSTALLATION OR REPAIR OF UNDERGROUND UTILITtES IN CITY STREETS OR IN CITY RIGHT-OF-WAY/EASEMENTS The following regulations and conditions constitute a part of the application made by any installer or contractor for the installation oi utilities in any City street right-of-way or City utility easement and the appiicant, in making his application to do such work, shall agree to abide by these regulations and conditions: 1. The individual obtaining the permit shall, before commencing such work, notify the City Engineer when the work at each location is to commence; and, when requested by the Engineer, shall submit plans and specifications. 2. Uaon comqletion of the proiect. the individual shall promntiv notifv the Citv Enqineerina Deqartment for final ins�ection. 3. The public is to be protected by the individual, at all times, from the commencement of the work until the completion and acceptance by the City. The installer or contractor shall so conduct his operations as to cause the minimum inconvenience to the public. The installer or contractor shall furnish, erect, and maintain, in accordance with the legally accepted standards, all necessary warning and tra�c control signs, barricades, traffic cones, and flashing lights to direct and control the movement of traffic through the project in all directions and at all times. The foregoing provisions shall not in any way relieve the installer or contractor of any of his legal responsibilities or liabilities for the safety of the public. 4. All openings in bituminous surfaces shall be cut in a straight line with sides smooth and vertical. No ragged edges will be permitted. Cutting shall be done with a concrete saw, cutting wheel, jack hammer, spades or similar approved tools. Backfill material shall be suitable for highway embankment construction. No peat, frozen lumps, broken asphalt, sod, roots, or other undesirable material shall be permitted as backfill. Rocks larger than six inches (6") in diameter shall not be used in backfilling of trenches. The back�ll material shall be placed in layers not to exceed one foot (1') and mechanically compacted to not less than 95 percent of modified Proctor density. The upper six inches (6") of the backfill shall meet Minnesota Highway Department Specifications for Class 5 material and shall be compacted to not less than 95 percent of modified Proctor density. As soon as possible after back�ll operations are completed, the cut bituminous edges of the Vench shall be painted with an asphalt emulsion such as SS-1. Immediately thereafter, the patching material shall be placed and mechanically compacted to not less than 95 percent of modified Proctor density. The asphaltic material used in patching shall be of the same type as removed from the roadway, except, that in no case, will a plant mixed asphalt of less quality than Minnesota Highway Department Specifications 2331 be used. The finished surtace of the patch shall conform to the surface of the undisturbed roadway. No permanent asphalt patches shall be on any base whose temperature is 32 degrees Fahrenheit or less. Cold weather patching shall be of temporary nature, using cold mixed asphalt, well graded crushed rock or similar approved materials. Temporary patches shall be true to line and grade. Temporary patches shall G:\PERMITS\ROW Utility�ROW PERMITS.doc be replaced by permanent patches when weather conditions permit and notification shall be required as stated in 2. 5. Other areas may be required to be compacted at the direction of the City Engineer. 6. Such permittee to be responsible for maintenance and repair of all trenches for a period of one (1) year and if settlement occurs or excavation caves in, the same shall be prompUy indicated by adequate warning signs and shall be restored to proper condition in accordance with specifications above provided as soon as conditions permit. 7. All culverts and ditches shall be replaced in their original position and condition existing prior to construction and no change shall be made in drainage without approval of the City Engineer. 8. Permittee shall save the City harmless from all third party claims for injury or damage which may occur between the time the work commences and the time it is finally accepted by the City. 9. The permittee may be required to jack or bo�e under certain streets, as determined by the City Engineer. 10. The applicant shall furnish evidence of public liability insurance of not less than $100,000/300,000 and property damage of not less than $25,000 issued by an insurance company authorized to do business in the State of Minnesota on which the City is named as an additional insured party. 11. Except for the negligent acts of the City, its agents and its employees, the permittee shall assume all liability for, and save the City, its agents and its employees, harmless and defend same at its sole cost and expense from any and all claims for damages, actions or causes of action arising out of the work to be done herein and the continuing uses by the permittee, including but not limited to the placing, constructing, and reconstructing, maintaining, protecting and use of said facility under this application and permit for construction. 12. Existing Facilities - The utility facility and installations shall not interfere with any existing utility facility on the City's right-of-way or easements. It is the responsibility of the applicant to call for necessary locations of existing utilities. (Gopher One) 13. Private Property - The work permit or permit for construction as issued does not in any way imply that the appropriate easement exists to allow the applicant to work on private property. 14. Cutting Trees - The permission herein granted does not confer upon the permittee the right to cut, remove or destroy trees or shrubbery within the legal limits of the right-of-way. Easements that are not specifically identified on the plan attached to this permit or relieve permittee from obtaining any consent othervvise required from the owne� of the property adjacent thereto. 15. Clean-Up - Street, trailways and affected right-of-way shall be scraped clean at the end of each work day and swept clean after construction is completed and left in a neat and presentable condition. 16. Replacement of Sod - Wherever top-soil and sod are disturbed, they shall be replaced in kind and maintained satisfactorily until the turf is established. The undersigned hereby declares he/she has read and will comply with all the PERTINENT REGULATIONS as stated above and relevant City Ordinances. DATE: , SIGNED: � ! - v� G:\PERMITSVtOW_Utility�ROW PERMITS.doc A�a�"��, CERTIFICATE OF LIAB�LITY �NSURANCE o ATE(MM/DD/YyW) 07/17/20�6 PRODUCER 7H►S CERTIFICATE IS ISSUED AS A MATTEFt OF INFORMATION Max 2nWu.ranae Agency G.r.oup, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 45�2 pu.an�iao Lane S1;e R HOLDER, THIS CERTIFICATE DOES NOT AIUIEND, EXTENb bR Plymr�uth, MN 559 9 6 ALTER THE COVERAGE AFFORDEp 8Y THE POLICIES BEL,O . _,. _ _, INSURE AFFORDING COVERAGE NAlC # iNSUReo INBURERA: TnL'� +:ai; Mutudl CuxbSidP Lawn Car� & Irriga.�ioa� INSUReR B: 908� W;,n.dsor Ct --° -- S�v�ge, t�N 55378 1NSURERC� _...._... ..— IN9UREFt o: INSURER E: H` COVERAGES THE POLICIES OF INSURANCE IISTED BELOW NAVE BEEN ISSUED TO THE INSURED NAMED AEOVE FOR THE POIICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDRION OF ANY CONTRACT OR OTHER DOGUMFNT WITN RESPEC7 7Q WHICH THlS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN 15 SUBJECT TO �11.L THE TERM3. EXCLUSIONS AND CONDITIONS OF SUCH POUCIES, AGGRCGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CUiIMS, iNSR oo.� -.� ,,__ ..... POLICY NUMBER PQLICV EFF� VE POLICY EXPIRATION LiM113 .-- GENBRAL LIABILITY enct•� ocCURRENCE S .� � O O O� O O U �1 k CO�IMERCIALGENERALLIABILIIY CT1223687 06/30/2006 06/30/2�07 _pg�� occurernxf � 100, 000 •-. ... _ ., � ClAIM3 MAOE n OCCUR MED EXP �Any ono peraon) E 5, 0 0 0 _ _ —.. .. -- PERSONAI_ $ ApV INJllRY $ �. � O O O�(J O O GENFRq4_A40REC�ATE $ %� O O O � O O O OEN'L AGGREGAIE LIMfTAPPI,lFS PEA' PRODUCTS - CO7viPJ00 AGG 3 i� O O O� O O O POLICY � LOC " � AUTOM08R.E LIABILITY COM8INED 31NGLE LIMIT � �� (� � Q O O A x ANYAUTO CI•�122368A 06/30/2006 06/30/2007 (EaacelCenl) AI.I.OWNEO AUTOS , � _ 9CHEOULED AUTOS BODILY INJURY � 1Pet por.,on) x HIRFDAUT09 " "- X NON•QWNF.p AUT09 BOOILY INJURY � (Per Hceleern� oo+nad Pr�.v.irq nneA, Aul•oa PftOPERT(D/IMAGE OV11R0 A17tOA d/T i,';�v Pnp7� ((�8�lCC�i�f1t� '� OARAOE LIneILITY AUTO aNLY - EA IICCIDENT 8 nNYnUTO fAACC_ A �~ OT11ER TMAN AUTO ONLY: p �� S excessruneeae��.n�wea,n• [�CtaOGGU � ],, pQO, 000 � X occuR �I CUIIM3AMDE 0�1223685 06/30/2006 OG/30/2007 nGGR�GATE s J., 000, 000 $ ..._— DEDUCTIBLF " ` — Y RCTENTION $ � � a "" — WORKERS COfUPEN9ATi0N AND WC STATU. QTH- EMPt,0YER4' LU191LITY �RYJJMIT _CR '� nNVPRpPPIETpRIPARTNERlEXECUTIVE W�P1 %?3686 06/30/?_0(16 �6/��/2�Q� ELEACNACGDENT 7 50�,�1)� OFFICER�A7EMBEp EXGLUDED7 � nyt� da.:oriheunder E.L DISEASF-EAEMPL�YE s 500 000 SPECIAL PROVISION3 below G,L, DISFASE - PQLIdY LIMlT $ J 0 0, Q 0 0 OTNER DESCRIPTION OF OPEAATION9/ LOGATIONS 1 VEMCLES / E7(C{,413�OF7g ApDL•D BY ENDORSEMEµt J$PECUIL pROVI3WNS SS.te: 16691 & 1673:1. F�wy 13 S Prior ,L.�ke, MN 55372 CERTIFICATE HOLDER CANCELLATIOIV SNOVLO ANY OF THE A80VE DESCRIB6D pp1,�dES BE CJiNCELLED BF�ORE TNE EXPIRATION C�LS! O� p.ra,or. Lake pqTE THERHOF, THE IS9UIN0 IN9URER WILL ENDEAVOR TO MAIL � DAYS WRI'�7EN ,�tt: Nzthan Er.a.ese 16?_ 00 Eaqlo CreF k Ave 3� N�I� TO TNE CERTIPICATE HOI.GER NAMED TO TWE LfFT r�r FaiwRe ro 0o so s►�a�,� Prior I� �ke, MN 5J372 IMPOS� NO OBU6ATION OR LIA6111TV Of �NV KIND UPON THE INSUfiEN, ITS AGENTS OR �52-497-4?.H3 RE ENTATN AUTI{OAIZH E TATNQ IMPORTANT If the ce�tificate holder is an ADDITfONAL )NSUREp, the policy(ies) must be endorsed, A statement on this certificate does not confer rights to the certificate holde� in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement en this certificate does not oonfer rights to the certificate holder in (ieu of such endorsement(sj. DISCI�#IMER The Certificate of Insuranoe on the reverse sid� of this form does not constitute a contract betwe�n the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does It affirmatively or negatively amend, extend or alter the coverage afford�l by the policies listed thereon. MSC\C7233130\DVGSV Tltle.dx 03-29-20M1 823 un � � r� � i:i il � 11�I� �i i�;l I�ii �� . „I � , � � • I � +� 9 • 9 II I 1 � I I � � � • • I I •� O T 0� ■�(�' � I I � � G W� 2 S•° `� i �� t t 4 0•• 4� I � v ■ O h �� II x I E i ' I �■ I I 9 II I I � � u I � � � I 1 . �„ I 1 1 I . I;I i ' II� I 1 I i I I' � I I i � ( I I �:� .�� I� I� �� $ �g� ��€ g� �� g �� Y�� '� p� �� go �� '�� ' �� ho��i �� d � � � Z � �i � �� s �� K z � � � ��_�� m p > y � �� ° > � � � `� 5 K C � �� O y �d C� � � �y � � � •. . � � (`�_ . • ' i � � � �' � y � a o � � � �=;: .. : .,, a o � . t� � a � :.r. 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