HomeMy WebLinkAbout15966 Sunfish Trl ROW Permit 4.
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PERMIT Q
TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENT
AND
APPLICATION FOR INSTALLATION OF UTILITIES
1. Location � S`� �O �° SU�]J� I S�1 T'�.1. . S. E. ��j�' ��J `� �'P
2. Nature of Work »`S��-�-- SMALL V�..TtUT1ES
3. indicat� below items to be affec�ed and ir.clude a sket�h cr plan of wo!-k to be done.
Curb & Gutter Street Surface
TraiUSidewalk Trees:
Pond/Wetlands (Publically owned
Traffic Control Devices/Signs or Privately owned _�
Drainage Utilities
StructureBuildings Other ��W BLV 1� . •
4. Method of Installation or Construction bAC..I<K�E AND 4LOW �
5. Work to start on or after: S`�' � and shall be completed by: Z DA4S unless an extension
granted to: by:
DATE STAFF/DATE
6. Will detouring of traffic be necessary? N� If necessary to detour traffic, describe suggested
route:
7. Provide with this application a copy of the contractors Pubiic Liability Insurance.
DETOURS: T'he Director of Public Works shall be notified in writin� at (east 72 hours in advance of
any detour being established, changed or discontinued.
NAME OF APPLICANT =� �E��� ��- �� PHONE RSZ
PLEASE PRINT FAX q52- 22.(0 - 375�
ADDRESS 41o91a C01.GR14�D St. S�E, PR1UR. l.A1Z'E_. MN 553'�2.-[�Z.
STREET CITY STATE ZIP
NAME OF PARTY OR ORGANIZATION PERFORMING WORK
CONTACT PERSON: �N $ AR��� EMERGENCY (24 HR.) PHONE #: �� Z' 91 °I - S A S �
ADDRESS DAY PHONE q52- Z'Zlv - 7�f�4
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•� �" � � Title: �� B� � �` ER--� Date: � � `$ � ��
�avE '�L�HETL
79
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�XHIBIT "C"
FOR CITY USE ONL1^ •� AUTHOI�IZ��'ION OA P$Rl�1IT �.• •
FINANCIAL SECURITY: = AM.OUIVT: ' . ;. ! TYPE: ; '
(Cash, bond, LOC etc.)
Fee: $ sZS�- �v Receipt No. . 1� 77 Permit No. V-4cs'�
LIABILITY INSURANCE PROVIDED:
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 at zi�seribed'in the above lpplication, said work to be done in accordance with special provisions as
hereby stated:
. ,
,_� . .
APPROVED BY: DEPT. Or PUBLIC WORKS
By: /,� 7 a�
� � /DATE
ALL LEGAL REQUIREMENTS SHOWN ON PAGE ONE (1) AND ON ALL "SPECIAL PROVISIONS" SHALL
BE COMPLIED WITH. THE DATE WHEN WO[tK IS COMPLETED MUST BE REPORTED TO THE CITY
OF PRIOR LAKE C!TY ENGINEER.
80
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EXHIBIT "C"
CITY OF PRIOR LAKE
REGtJLATIONS PERTAINING TO THE INSTALLATION OR
REPAIR OF UNDERGROUND UTILITIES IN CITY STREETS
OR IN CITY RIGHT-OF-WAY/EASEMENTS
The following regulations and conditions constitute a part of the application made by any installer or contractor for
the installation of utilities in any City street right-of-way or City utility easement and the applicant, in making his
application to do such work, shall agree to abide by these regulations and conditions:
1. The individual obtaining the permit shall, before commencing such work, notify the City Engineer when
the work at each location is to commence; and, when requested by the Engineer, shal( submit plans and
specifications.
2. [ T��n compietic�n of the nroject, the ir.dividua: shalt promptiv notify the Cih��gine�ring,�e_p�r'-n!�n± ior
final inspection.
3. T'he public is to be protected by the individual, at all times, from the commencement of the work until the
completion and acceptance by the City. The installer or contractor shall so conduct his operations as to
cause the minimum inconvenience to the public. The installer or contractor shall furnish, erect, and
maintain, in accordance with the legally accepted standards, all necessary warning and traffic control signs,
barricades, tra�c cones, and flashing lights to direct and control the movement of traffic through the
project in all directions and at all times.
The foregoing provisions shall not in any way relieve the installer or contractor of any of his legal
responsibilities or liabilities for the safety of the public.
4. All openings in bituminous surfaces shall be cut in a straight line with sides smooth and vertical. No
ragged edges will be permitted. Cutting shall be done with a concrete saw, cutting wheel, jack hammer,
spades or similar approved tools.
Backfill material shall be suitable for highway embankment construction. No peat, frozen lumps, broken
asphalt, sod, roots, or other undesirable material shall be permitted as backfill. Rocks larger than six inches
(6") in diameter shail not be used in backfilling of trenches.
The backfill material shall be placed in layers not to exceed one foot (1') and mechanically compacted to
not less than 95 percent of modified Proctor density.
The upper six inches (6") of the backfill shall meet Minnesota Highway Deparhnent Specifications for
Class 5 material and shall be compacted to not less than 95 percent of modified Proctor density.
As soon as possible after backfill operations are completed, the cut bituminous edges of the trench shall be
painted with an asphalt emulsion such as SS-l. Immediately thereafter, the patching material sha(1 be
placed and mechanically compacted to not less than 95 percent of modified Proctor density. The asphaltic
material used in patching shall be of the same type as removed from the roadway, except, that in no case,
will a plant mixed asphalt of less quality than Minnesota Highway Department Specifications 2331 be
used. The finished surface of the patch shall conform to the surface of the undisturbed roadway.
No permanent asphalt patches shall be on any base whose temperature is 32 degrees Fahrenheit or less.
Cold weather patching shall be of temporary nature, using cold mixed asphalt, well graded crushed rock or
similar approved materials. Temporary patches shall be true to line and grade. Temporary patches shall be
replaced by permanent patches when weather conditions permit and notification shall be required as stated
in 2.
81
- �
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EXHIBIT "C"
� 5. Other areas may be required to be compacted at the direction of the City Engineer.
6. Such permittee to be responsibie for maintenance and repair of all trenches for a period of one (1) year and
if settlement occurs or excavation caves in, the same shall be promptly indicated by adequate warning signs
and shall be restored to proper condition in accordance with specifications above provided as soon as
conditions permit.
7. All culverts and ditches shall be replaced in their originai position and condition existing prior to
construction and no change shal( be made in drainage without approval of the City Engineer.
8. Permittee shall save the City hannless from all third party claims for injury or damage which may occur
between the time the work commences and the time it is finally accepted by the City.
9. The permittee may be required to jack or bore under certain streets, as determined by the City Engineer.
10. The applicant shall fum�sh evidence of public liability insurance of not less than $100,000/300,000 and
property damage of not less than $25,000 issued by an insurance company authorized to do business in the
State of Minnesota on which the City is named as an additional insured party.
l l. Except for the negligent acts of the City, its agents and its employees, the permittee shall assume all
liability for, and save the City, its agents and its employees, harmless and defend same at its sole cost and
expense from any and all claims for damages, actions or causes of action arising out of the work to be done
herein and the continuing uses by the permittee, including but not limited to the placing, constructing, and
reconstructing, maintaining, protecting and use of said facility under this application and permit for
construction.
12. Existing Facilities - The utility facility and installations shall not interfere with any existing utility facility
. on the Ciry's right-of-way or easements. It is the responsibility of the applicant to call for necessary
locations of existing utilities. (Gopher One)
13. Private Property - The work permit or permit for construction as issued does not in any way imply that the
appropriate easement exists to allow the applicant to work on private property.
14. Cutting Trees - The permission herein granted does not confer upon the permittee the right to cut, remove
or destroy trees or shrubbery within the legal limits of the right-of-way, easements that are not specifically
identified on the plan attached to this pe:mit or relieve permittee from obtaining any consent otherwise
required from the owner of the property adjacent thereto.
15. Clean-Up - Street, trailways and affected right-of-way shall be scraped clean at the end of each work day
and swept clean after construction is completed and left in a neat and presentable condition.
16. Replacement of Sod - Wherever top-soil and sod are disturbed, they shall be replaced in kind and
maintained satisfactorily until the turf is established.
The undersigned hereby declares he/she has read and will comply with ali the PERTINENT REGULATIONS as
stated above and relevant City Ordinances.
DATE: �' � O — 2 � �� SIGNED: �
82
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PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
MARSH USA INC. NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE
111 S.W. COLUMBIA POLICY. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE
FIFTH FLOOR AFFORDED BY THE POLICIES DESCRIBED HEREIN.
PORTLAND, OR 97201 COMPANIES AFFORDING COVERAGE
Attn: P: 503-248-6400 F: 503-248-1220
COMPANY
02538-1-Integ-05-06 A FEDERAL INSURANCE COMPANY
INSURED . COMPANY
Integra Telecom of Oregon, Inc. B PACIFIC INDEMNITY COMPANY
1201 NE Lloyd Blvd., Suite 500
Po�tland, OR 97232 COMPANY
C
COMPANY
D
CQV�RAGES This certificate supersedes and replaces any previausly issued'certificate for the policy period noted below. 2
THIS IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR MAY
PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CONDITIONS AND EXCLUSIONS OF SUCH POLICIES. AGGREGATE
LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POIJCY EFFECTIVE POLJCY EXPIRATION LIMITS
LTR DATE (MM/DDIYY) DATE (MMIDD/YY)
A GENERAL LIABILITY 35348475 12/15/05 12/15/06 GENERAL AGGREGATE $ 2, ��� , ���
X COMMERCIAL GENERAL LIABILITY pRODUCTS - COMP/OP AGG $ 2,000,000
CLAIMS MADE � OCCUR PERSONAL 8 ADV INJURY $
OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $ �,OOO,OOO
FIRE DAMAGE (Any one fire) $ �
MED EXP An one erson $ � �,���
A AUTOMOBILE LIABILITY 7325q2gg 12/15/05 12/15/06 COMBINED SINGLE LIMIT $ �,���,���
X ANY AUTO
ALL OWNED AUTOS BODILY INJURY $
(Perpersan)
SCHEDULED AUTOS
HIREDAUTOS BODILYINJURY $
� � (Per accident)
NON-OWNED AUTOS
� PROPERTY DAMAGE $
GARAGE IJABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
B EXCESS LIABIIJTY 79692109 12/15/05 12/15/06 EACH OCCURRENCE $ 2,00
UMBRELLA FORM AGGREGATE $ 2,000,000
X OTHER THAN UMBRELLA FORM $
A WORKERS COMPENSATION AND 7170-63-99 �]/����6 12/01/06 X TORY LIMITS ER �
EMPLOYERS' LIABILITY SOO,OOO �
EL EACH ACCIDENT $
THE PROPRIETOR/ INCL EL DISEASE-POLICY LIMIT $ SOO,OOO
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL EL DISEASE-EACH EMPLOYEE $ 500,
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
�F����#�Y�� ��� f�F� �� ; �II � ����II li �+ V�CI I ��Iry� � �I�f,��,� iiflll il .��I �P I�. �����' I � �'x � r I ��II�������� NR I�I� I �,
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SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELIED BEFORE THE EXPIRATION DATE THEREOF,
7HE INSURER AFFORDING COVERAGE WILI ENDEAVOR TO MAIL _3Q DAYS WRITTEN NOTICE TO THE
CITY OF PRIOR LAKE CERTIFICATE HOLDER NAMED HEREIN, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
Attn: Engineering
16200 EAGLE CREEK AVE. SE LIABILITY OF ANY KIND UPON THE iNSURER AFFORDING COVER4GE, ITS AGENTS OR REPRESENTATIVES, OR THE
PRIOR LAKE, MN 55372 ISSUEROFTHISCERTIFICATE.
MARSH USA INC. .
sy: Cheri L. Summerton �-L�.�.u. �(• �u�»,»a.�"rw
:< ,� I� �Il,lli��, �IIII'II�I'il � I iihl II� �,'� I u � il� s �IIIII�� �, �.�i�11���' �,II � ,� , i� "1 VALID AS OF �07/10/06 ���f
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