HomeMy WebLinkAbout15135 Jeffers Pass ROW Permit • .� ; .
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� C=1 WORK ORDER � 3(oG(c ��
�, PERNIIT
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TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS
AND
APPLICATION FOR INSTALLATION OF UTILITIES •
1. Locarion %S /-3.� \-I'��F/�`�2 S J�/��SS y
2. Nature of Work ��� � a ��� G �' S �� �/� �
3. Indicate below items to be affected and include a sketch or plan of work to be done.
Curb & Gutter Street Surface
TraillSidewalk Trees:
Pond/Wetl�ds (Publically owned
Traffic Control Devices/Signs or Privately owned ____)
i Utilities
Drainage � Other �"a k�� �L � 6 hfiSS
StructureBuildings
4. Method of Installation or Construction �� ������ �'
5. Work to start on or after: �� �� � si►d shall be completed by: � r �- ° ^�`� unless an extension
• � granted to: y�
DATE STAFF/DATE �
6. Will detouring of traffic be necessary? N � If necessary to detour tra�c, describe suggested
route:
7. Provide with this application a copy of the contractors Public Liability Insurance.
DETOURS: The Director of Public Works shall be *+�t;f P� +^ e�^tine at least 72 hours in advance of
any detour being established, changed or discontinued.
CenterPoint Energy, Minnegasco pgp� 612
NAME OF APPLICANT pLEASE PRINT FAX �12-321-5480
ADDRESS �00 Linden Avenue West, P.O. Box 1165, Minneapolis, MN 55440-1165
STREET CITY STATE �
NAME OF PARTY OR ORGAI�TIZATION PERFORMING WORK
Michels Corp.
CONTACT PERSON: Dale Anderson EMERGENCY (24 HR.) PHONE #: 612-369-4504
ADDRESS . DAY PHONE
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 �+ c mply therewith to the satisfaction of the City of Prior Lake.
' Title: Eng . As s i s t. Date: � J ' - � �� 7 �
Signed:
� Page 1 of 4
16200 Eagle Creek Ave. S.E., Prior Lake, Minnesota 55372-1714 / Ph. (612) 447-4230 / Fax (612) 447-4245
AN EQUAL OPPORTUNITY EMPLOYER
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EX�iIBIT "C» __
'
FOR CTfY USE ONLY AUTHpRIZqTION OF PERMIT
FINANCIAL SECURITY: AMOUNT:
TYPE: :
(Cash, bond, LOC etc.)
F �� �— ���� �� Receipt No. �
Permit No. vld �� �
I-U Associated Electric & Gas Insurance Services Limited
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 Ciry 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 with special provisions as
hereby stated:
� � APPROVED BY; DEPT. OF PUBLIC WORKS
By:!� C �1����3.%�`�..__�- �L�'j� .
/DATE '
ALL LEGAL REQIIIREMENTS SHOWN ON PAGE ONE (1) AND ON ALL "SPECIAL PROVISIONS" SHALL
BE COMPLIED WITH. Tf� DqTE WI�N W�� IS COMPLETED MUST BE REppRTED TO TI� CITY
OF PRIOR LAKE CITy ENGINEER .
.
�'�� Page 2 of 4
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