HomeMy WebLinkAboutJeffers Pass & Eagle Creek Ave ROW Permit r .
EXHIBIT "C"
PERMIT
TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS
AND
APPLICATION FOR INSTALLATION OF UTILITIES
S�. F FERS �O IJD
1. Location NEW DEVEIAPM�,NT AT 1�FF�RS PASS NUJ At�1� EAGI.E CP.EE.K AYE IJE
�UB# O -ODS�
2. Nature of Work PLAC'EMFJJT OF aUR1'ED ��1DN�. CABL'� RIJ� IIJNEJZDUCT'
3. indicate bel�w i±ems to be affecred an� ir.�lude_a,sket�h cr plar! of work to be done.
�� _ ,� , . ,
Curb & Gutter - Street Surface
TraiUSidewalk � � ` ` �— Trees:
Pond/Wetlands (Publically owned
Traffic Control Devices/Signs or Privately owned _�
Drainage Utilities
ShuchueBuildings Other � � ' �LV �
4. Method of Installation or Construction TRACKI-10E - BRC�H OL- "
5. Work to start on or after: �'Z�O `�S and shall be completed by: ( s D 0 . 4 S unless an extension
granted to: by:
- DATE STAFF/DATE
6. Will detouring of traffic be necessary? (�10 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 =� TG.C� E�� ��..L��� ���°�.. PHONE RSZ-`t47
PLEASE PRINT FAX 952- 22.(n - 375�a
ADDRESS �qL� CQtbRl4bb St. 5,�, P�ID'�... LA�Z� MN 553� 2 - C�Z..9�.
STREET CITY STATE ZIP
NAME OF PARTY OR ORGANIZATION PERFORMING WORK
CONTACT PERSON: �N $AR��'�- EMERGENCY (24 HR.) PHONE #: �� Z 9� g ' S�' 4l
ADDRESS DAY PHONE q52- 2'Llo - 7fl�u4
STREET CITY STATE ZIP -
The undersigned herewith accepts the terms and conditions of this permit by the City of Prior Lake as herein
co ' ed an to fully comply therewith to the satisfaction of the City of Prior Lake.
Sign • Title: ����NEE� Date: � � 2 � ���
79
. r
�XHIBIT ��C"
FOR CITY USE ONLY AUTHORIZATION O� PERMIT
FINANCIAL S�CURITY: AMOUNT: TYPE:
(Cash, bond, LOC etc.)
Fee: $�S S�•�v Receipt No. 1K y �ermit No. - 4�
LIABILITY INSURANCE PROVIDED: f��y�►II� ���C �'^
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 du(y 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 specia! provisions as
hereby stated: .
APPROVED BY: DEPT. Or PUBLIC WORKS
By: �i�i� !"���.�
/DATE
ALL LEGAL REQUIREMENTS SHOWN ON PAGE ONE (1) AND ON ALL "SPECIAL PROV[SIONS" SHALL
BE COMPLIED WITH. THE DATE WHEN WORK IS COMPLETED MUST BE REPORTED TO THE CITY
OF PRIOR LAKE C?TY ENGINEER.
_ Y
80
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