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HomeMy WebLinkAboutCR21 & Eau Claire Trl ROW Permit . � C�C��O�]C� SEP 1 2 2005 e rN i ��RR 5o Q�k os- o s� P PERMIT TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS AND APPLICATION FOR INSTALLATION OF UTILITIES 1. Location 4 CAST OF CoR,D al — R� LRaSSI'iU6 OF L�AU CLAIRE TRL. 2. Nature of WorkWDRK liEING 4oA/� �U� 7c� REBO��.ID or- Co.RO.. �I - c.zTroF pR►oR LahC �og # 03- SC�"Il' CNT�I _ �nB 7D • �82-o I . 3. indicate bel�w items to be affecrtid and ir.clude a sket�h cr �lan. of work to be done. Curb & Gutter Street Surface TraiUSidewalk Trees: Pond/Wetlands (Publically owned Tra�c Control Devices/Signs or Privately owned _� Drainage Utilities StructureBuildings Other R/ W BI.V D` 4. Method of Installation orConstruction Trt1�STALL aSPR TEL �A�BL� L3Y PIOW AAJ�O PIJVM� C��PH Lr' R 5. Work to start on or after: 9-Zfe-DS and shall be completed by: � DA� unless an extension granted to: by: DATE STAFF/DATE 6. Will detouring of traffic be necessary? N 0 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 hoLrs in advance of any detour being established, changed or discontinued. NAME OF APPLICANT = N���'�� ��t- ��-U �,��-- PHONE `� S Z `�'�" S�'' � PLEASE PRINT FAX 9 52 - 22.(0 - 3 � 5 a ADDRESS 41o9ta CdLbR14�D St. 5,�., fi'R1OiC. LA1ZE.. MN 55372.-bZ. STREET CITY STATE ZIP NAME OF PARTY OR ORGANIZATION PERFORMING WORK CONTACT PERSON: �N $AR-��E- EMERGENCY (24 HR.) PHONE #: �+� Z' 9 � ° � '� 8 S � ADDRESS DAY PHONE a52-' 22Lo - 70(p4 STREET CITY STATE ZIP _ The undersigned herewith accepts the terms and conditions of this pecmit by the City of Prior Lake as herein cont ' ed and o fully comply therewith to the satisfaction of the City of Prior Lake. Signe • Title: �-�B�N�E� Date: T' � Z'�� 79 �XHIBIT "C" FOR CITY USE ONLY, AUTHORIZATION OI' PERMIT FINANCIA�. SECURIT`,l: AMQUNT: __TYPE:. (Cash, bond, LOC etc.) Fee: $ �' Receipt No. '""� Permit No. 'G LIABILITY 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 tfte above application, said work to be done in accordance with specia( provisions as hereby stated: . APPROVED BY: DEPT. OF PUBLIC WORKS g /•�� �"�s2S� � /DATE ALL LEGAL REQUIREMENTS SHOWN ON PAGE ONE (1) AND ON ALL "SPECIAL PROVISIONS" SHALL BE COMPLIED WITH. THE DATE WHEN WORK 1S COMPLETED MUST BE REPORTED TO THE CITY OF PRIOR LAKF CITY ENGINEER. 80 y � M "' °. 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