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HomeMy WebLinkAboutFive Hawks Ave & Tranquility Ct ROW Permit �. � EXHIBIT "C" PERMIT TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS AND APPLICATION FOR INSTALLATION OF UTILITIES 1. Location ��VE L1A11UKS AVE s.E TO "fRAN(9.UIL1T� cz. sE. TbB� 05 -�35� 2. Nature of Work p��M� aF �UR.1E� VH�N� CA6l.E, AND 1NNERDUC,T 3. indicate below items tn be affec�ed and ir.clude a sketch or nlsn of wo�k to be done. Curb & Gutter Street Surface TraiUSidewalk Trees: Pond/Wetlands (Publically owned Traffic Control Devices/Signs or Privately owned _� Drainage Utiliti s StructureBuildings Other R�W " —� 4. Method of Installation or Construction LA'BLE �L4W -'P1�E-IIMA GO�i��. 5. Work to start on or after: �' �� and shall be completed by Z DAy S unless an extension granted to: by: DATE STAFF/DATE 6. Will detouring of traffic be necessary? �� 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 writine at least 72 hoLrs in advance of any detour being established, changed or discontinued. NAME OF APPLICANT =N ��.C��F�. T�.L��.� �'� ��.. PHONE QSZ- PLEASE PRINT FAX q52- 2Zlo - 375E3 ADDRESS '`� t�dLOltl4tab St, S,E., Pt�1�i� LA1Z�. IV1N 553'iZ- AZ9Gt STREET CITY STATE ZIP NAME OF PARTY OR ORGANIZATION PERFORMING WORK TTAnER ; N►Gl�S1R�M CONTACT PERSON: �N $A��'�� EMERGENCY (24 HR.) PHONE #: � � Z' 91 °I - S P S l ADDRESS DAY PHONE q52-' ZZIo ' 7flfc�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 an to fully comply therewith to the satisfaction of the City of Prior Lake. Si • � Title: ���'�N �E� Date: �_ Z7 � � 79 � � EXHIBIT "C" FOR CITY USE ONLY AUTHORIZATION OF PERMIT FINANCIAL SECURITY: AMOUNT: TYPE: (Cash, bond, LOC etc.) Fee: $ �i�B ��� Receipt No. � ?ermit No. V�'Q�� LIABILITY INSUR.ANCE PROVIDED: 13M�c7/'�fJGC ��G�Ge7Z9✓� ��L�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 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 with special provisions as hereby stated: APPROVED BY: DEPT. OP PUBLIC WORKS . B S/�9 os /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 CITY ENGMEER. 80 �} Z � — o� � a �° ` z m ; � � � � �. � � � � � F e r VJ O '^ � C S S Q1 � ; , � � C C�d � � O h A N N � � +� � . 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