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HomeMy WebLinkAbout5821 Industrial Ln ROW Permit � _ "� � � r� _�� � EXHIBIT "C" PERMIT TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS APPLICATION FOR IN TALLATION OF UTILITIES ���� DS ��� S � 1. Location 58Z.f LND�I.STR.IAL Lrl -`PAWS RN� VALS -UEEIC.FIELD TND. PAIU 2. Nature of Work �� UT ���LH - M.u'P�L . SMI� Ll. U►.Z 1 L..ITI ES S E�.V 1 L.� �. indicate below items to be affecred and ir.clude a sketch cr �lan of wo�k to be done. Curb & Gutter Street Surface TraiUSidewalk Trees: Pond/Wetlands (Publically owned Tra�c Control Devices/Signs or Privately owned � Drainage Utilities StructureBuildings Other BLV D\ 11�.T 1(. (T! �Et�SE ME NT 4. Method of Installation or Construction bR(.at.H ��E ' 5. Work to start on or after: '�' ZS�OS and shat! be compieted by: 3 L�A�JS unless an extension oranted 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 writjn,g at least 72 hours in advance of any detour being established, changed or discontinued. NAME OF APPLICANT Z N����� ��-1- ��� �����-- PHONE R S Z S�'' PLEASE PRINT FAX 952- 22.l0 - 375E'a ADDRESS '�`�Q �w��b� St. S�IE� Pl�1Q'R.. LA{Z�. MN 5S'S'? Z- b2.°i�t STREET CITY STATE ZIP NAME OF PARTY OR ORGANIZATION PERFORMING WORK � CONTACT PERSON: �N $A���E- EMERGENCY (24 HR.) PHONE #: � � Z`°� �°� ' S Pr Sl ' �`` ADDRESS DAY PHONE Q52- 22(0 -�fllv4 STREET CITY STATE ZIP _ The undersigned herewith accepts the terms and conditions of this permit by the City of Prior Lake as herein contained and agree to fully comply therewith to the satisfaction of the City of Prior Lake. Signed:1 »-t�- j�-�,� Title: �N L�,1 N EER. Date: '�"' `� �� � J�flU� FL�T[_!-1�R. 79 . , EXHIBIT "C" FOR CITY U$E ONL�Y AUTHpRIZATION OF PERMIT FINANCIAL S�CURITY: � AMOUNT: TYPE: � (Cash, bond, LOC etc.) Fee: $ ds5� �� Receipt No. �_ ?ermit No. ' LIABILITY INSURANCE PROVIDED: �3�'9��� /'����/�1'[�✓� �✓�sV����. 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 duty given by said City of Prior Lake; permission is hereby granted for the work to be done as described in the above application, said work to be done in accordance �vith special provisions as hereby stated: , APPROVED BY: DEPT. OF PUBLIC WORKS � By . :%� ��- �/ :�(' ' ' /DATE ALL LEGAL REQUIREMENTS SHOWN ON PAGE ONE (1) AND ON ALL "SPECIAL PROVISIONS" SHALL BE COMPLIED W1TH. THE DATE WHEN WO[ZIC 1S COMPLETED MUST BE REPORTED TO THE CITY OF PRIOR LAKE C?TY ENGINEER. 80 .� -' m p m � � r a � � o � � ° � � -d � s, �y � � m +f�'� e � T � v F p � � � r1'� � a 0 z � rn �� �� � � � � z � � \ ~ �� ! 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