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
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