HomeMy WebLinkAbout5512 Woodside Rd ROW Permit EXHIBIT "C"
PERMIT
TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS
AND
APPLICATION FOR INSTALLATION OF UTILITIES
1. Location 5 �� S� D F K �,
2. NatureofWork ��'L►�� ��� ��UrcE Lln1C
3. indicate below items tr� be affected and ir.�lude a sket�h ar plsn of wo!�k to be done.
Curb & Gutter Street Surface
TraiUSidewalk Trees:
Pond/Wetlands (Publically owned
Traffic Control Devices/Signs or Privately owned _)
Drainage Utilities •
StructureBuildings Other ,$LV,D • •
4. Method of Installaltion or Construction �Z� � �
5. Work to start on ot after: �' ��'os and shall be completed by: I D RY unless an extension
granted to: � by:
DA E STAFF/DATE
6. Will detouring of {raffic be necessary? M� If necessary to detour traffic, describe suggested
route: '
7. Provide with this �pplication 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 APPLYCANT = N TEC�a�R T�LGC� ��`� pHONE Q'SZ
PLEASE PRINT FAX 952- 2Z(o - 375�
ADDRESS �q� ����� 5t. S�E, PRa�R. LA{2'� MN 55372-[�Z.9�t
' STREET CITY STATE ZIP
NAME OF PART!,Y OR ORGANIZATION PERFORMING WORK
CONTACT PERSION: �� $A��v� EMERGENCY (24 HR.) PHONE #: �� Z' 9 �°r ` S�f 8'1
ADDRESS DAY PHONE a52� 22.1n -']fl(n4
STR�ET CITY STATE ZIP _
The undersigned �erewith accepts the terms and conditions of this permit by the City of Prior Lake as herein
conta� nd fully comply therewith to the satisfaction of the City of Prior Lake.
Sign • itle: �������� Date: 7 �^��
I 79
� i1
�XHIBIT "C"
FOR CiTY USE ONLY , , . , A�lTF-�dFcIZATION OF;PERMIT `, : � .
FINANCIAL SECURITY: ' : � :AIv10UNT: ' _ � 'FY.PE: �
(Cash, bond, LOC etc.)
Fee: $ �(i� � Receipt No. l yl3 Permii No. �
LIABILITY INSURANCE PROVIDED: T/'v� /' ���0�'� �'^-
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 deseS'rbed�� the above application, said work to be done in accordance with special provisions as
hereby stated:
APPROVED BY: DEPT. OF PUBLIC WORKS
gy; /;�Yd�� 7''/�-�
� ` " ' /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 LAKF C1TY ENGINEER.
80
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