HomeMy WebLinkAboutMcKenna Rd & Thunderbird Cir ROW Permit 3 FROM (MON)JUN 72 2006 7:52/ST. 7:52/No.7S0000046 P 2
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�. PERMIT
�jNNES��
TO WORK WITHIN CITY PROPERTY/�tIGHT-OF-'WAY/EASEMENTS
AND
A,PPLICATION FOR INSTALLATION OF UTILITIES •
]. Location.�C:�` Q/i�'�� �1'! � ���d�--" ��j/�1� ��A�
2. Nature of Work � ����P—�� 0 ��� �`�–` �� jL�y� C��''�. � •
3. Indicate below items to be affected and include a sketch or plan of work to be done.
Curb & Gutter Street Surface
TraiUSidewallc Trees:
Pond/Wetlands (Publically owned
Traffic Control Devices/Signs or Privately owned __) �
Drainage Utilities .
StructureBuildings Other d7/��'I"� �/�!'��� �
4. Method of Instaliation or Construction �/ ��� ���' `� ~
5. Work to start on or after: � � and shall be completed by: 0 �� "' unless an extension
� granted to: by�
DATE STAFF/DATE .
6. Will detouring of traffic be necessary? � If necessary to detour traffic, describe suggested
route:
?. Provide with this application a copy of the contractors Public Liability Insurance.
DETOURS: The Director of Public Works shall be gQtified in writing at least 72 hours in advance of
any detour being established, changed or discontinued.
NAME OF APPLICAN't' Qcrest _PHONE
PLEASE PRINT FAX 612-861-81 73
ADDRESS6244 Cedar Avenue South Richfield MN 55423____
STREET CITY • STATE ZIP
NAME OF PARTY OR ORGANIZATION PERFORMING WORK Q�*p s*
CONTACT PERSON: Dan Narman ENFERGENCY (24 HR.) PHONE #:1-500-954-121 1
ADDRESS ���� �°a�.r Ave S,_,, Richfield MN 5542�AYPHO?�?E(�l�—Sthl_R
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.
Si;ned: Title: ��j,nPPr Date:
E��DITC.DOC Page 1 of 4
16200 Eagle Creek Ave. S.E., Prior Lake, Minnesota 55372-1714 / Ph. (612) 447-4230 / Fax (612} 447-4245
AN EQUAL OPPORTUNITY EMPLOVER
IEXHIBIT "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: $ i— Receipt No. � Permit No. �- '3 �
LIABIILITY INSURANCE PROVIDED: //�gtS �l U 3�'
In consitleration 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
B /.���--- �o I� �6
/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.
H:\Utility Pumits\City of Prior Lake�feple Glen 2 Pax 2.doc
FROM (MON)JUN �2 2006 7:53/ST. 7:62/No.75000004B3 P 3
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. DRAWING DISCLAIMER
�� �, C FACITILY LOCATIONS ARE GENERAL
NATURE Qwest WILL NOT BE HELD
ACCOUNTABLE FOR THE ACCURACY
OF THE INFORMATION PROVIDED ON
� . " THESE DRAWINGS
(� �i�t DY� O��
� orvJ � OrgD'J u/A-�/'
, �/00 PK
► � V� —� �' a '` e ,� 7"
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Qw �fT ,� Restore all disturbed surfaces to
�t� ��!'R N �Q �--"� originai or better condition
���.�- G GOPHER STATE ONE CALL
1 800 252-1166
ir �
(� ��� Qwest Engineer. GARRY YOHN
r 6244 Cedar Av S
M Richfield, MN 55423
Telephone Number 612-861-811 1
� Fa�c Number 612-861-8173
� COUNTY: �
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� WIRE CENTER:I J�'f'�KOO�E�
HUDSON: —St'9O
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