HomeMy WebLinkAbout5821 Industrial Ln ROW Permit �
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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.
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