HomeMy WebLinkAbout14049 Rutgers St ROW Permit (� O�
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EXHIBIT "C"
PERMIT
TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS
AND
APPLICATION FOR INSTALLATION OF UTILITIES
1. Location �� ��� R UTG �RS ST
2. Nature of Work R F P L�4 C. M C N T D F H D C�S ,� PN O�J E S E R UIc C M/11 NT�NA G E
CX�SZ'� N G S�t'411c.E 61.► Vh� . 1N E �� y � 3
3. Tndicate below items to be affec�ad and ir.clude a sket�h cr olsn of work to be done.
Curb & Gutter Street Surface
TraiUSidewalk Trees:
Pond/Wetlands (Publically owned
Traffic Control Devices/Signs or Privately owned _)
Drainage Utilities
StructureBuildings Other R.O.IN. '
4. Method of Installation or Construction B l� C, K M D C A �1.� C �4 R L E-� I D�V
t �A`I
5. Work to start on or after: �'�+' and shail be completed by:'�� unless an extension
granted to: by:
DATE STAFF/DATE
6. Will detouring of tra�c be necessary? N� If necessary to detour traffic, describe suggested
route:
7. Provide with this application a copy of the contractors Public Liabiliry Insurance.
DETOURS: The Director of Public Works shall be notified in writjpg at least 72 hours in advance of
any detour being established, changed or discontinued.
NAME OF APPLICANT Z N����� ��t- ��� ��-- PHONE °� 5 Z''`�47-37 SP:++
PLEASE PRINT FAX q52- 22.(0 - 375�a
ADDRESS �+�� ����°�'� St. S,IE� Pi�Oit.. �.A1c'�. MN __ 55'S7Z-AZ
STREET CITY STATE ZIP
NAME OF PARTY OR ORGANIZATION PERFORMING WORK
CONTACT PERSON: �N $A���'� EMERGENCY (24 HR.) PHONE #: �� Z' °� �°� ' S 8 a �
ADDRESS DAY PHONE q52-' 22�° ''fl!�'4"
STREET CITY STATE ZIP -
The undersigned herewith accepts the terms and conditions of this permit by the City of Prior Lake as herein
cont d an ree to fully comply therewith to the satisfaction of the City of Prior Lake.
Sign Title: �-��'�'N�E� Date: � - 2-5 ^— �s
79
. �
�XHIBIT "C"
FOR CITY USE ONLY AUTHORIZATION OF PERMIT
FINANCIAL SECURITY: AMOUNT: TYPE:
, (Cash, bond, LOC etc.)
Fee: $ �s� �d Receipt No. I3 y/ ?ermit No. ��
LIABILITY INSURANCE PROVIDED: 1�r4�i''ul.� �i��e lU'
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 lpplication, said work to be done in accordance �vith special provisions as
hereby stated:
APPROVED BY: DEPT. OC PUBLIC WORKS
.
By: j� `�L - -- -- � Q�
/DATE
ALL LEGAL REQUIREMENTS SHOWN ON PAGE ONE (1) AND ON ALL "SPECIAL PROVISIONS" SHALL
BE COMPLIED WITH. THE DATE WHEN WOItK IS COMPLETED MUST BE REPORTED TO THE CITY
OF PRIOR LAKE C?TY ENGINEER.
80
�� N
13000
This drawing is neither a legally recorded map nor a survey
and is not intended to be used as one. This drawing is a
compilation of records, information and data frqm various
city, county and state offices and otMer sources. This document ::
should be used for reference only. No representation is m�de .�
that features presented accura�tely reflect true Ioeation. The
City of Prior Lake, or any other ent'rty from which data was
' obtained, assumes no liability for a�y errors pr omi$sions herein. :`;
`; If discrepancies are fvund, plea�e corrtact the City of Prior Lake. :
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