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HomeMy WebLinkAbout6278 150th St to Estate Ave ROW Permit EXHIBIT "C" PERMIT TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS AND APPLICATION FOR INSTALLATION OF UTILITIES 1. Location �Z�� 1SOTH ST: TO ESTA'IE AVE. �$# Q�"'Q�{"�J� 2. Nature of Work ��- 7GURlED PttO11E. UlBt�. 3. Tndicate bel�w items to be affected and ir.�lude a sketch ar plan of wo! 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 T�W + aW D. ` 4. Method of Installation or Construction �EL-� ��-t�J � 5. Work to start on or after: �' 2' 0 '�' and shall be completed by: � Dpy 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 Public Liability Insurance. DETOURS: The Director of Public Works shall be notified in writing at least 72 hours in advance of any detour being established, changed or discontinued. NAME OF APPLICANT =N �EC��R ��LG�.� P�� PHONE QSZ--`�47 PLEASE PRINT FAX q52- 22.fo - 375� ADDRESS 4foCt ta CQLDRY+r1aD St. S�fi. � PR1AR �A1Z'E M N 5 537 2- L� Z.9�i STREET CITY STATE ZIP NAME OF PARTY OR ORGANIZATION PERFORMING WORK CONTACT PERSON: �N $AR-�G� EMERGENCY (24 HR.) PHONE #: �� Z 91 q - S A f.4 � ADDRESS DAY PHONE q 52 - 221.� - 7 fl fn4 STREET CITY STATE ZIP _ The undersigned herewith accepts the terms and conditions of this permit by the City of Prior Lake as herein con ' ed and ree to fully comply therewith to the satisfaction of the City of Prior Lake. Signe . Title: �-��� N E�� Date: 7- Z Z- 0 4 79 �XHIBIT "C" FOR CITY �JSE ONLY , � AUTHQRIZA'�ION OF PE�tM1T � , • , . _ FINANCIAL SECURITY: AMO.UNT: ' _ . .T1';PE: (Cash, bond, LOC etc.) Fee: $�Jd ��' Receipt Na 5 G Permit No. u' ' 6 LIABILITY INSURANCE PROVIDED: 1: 'T�� �IG(��eT[9'^ .L.�Svrti�[ t 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 tl�e above application, said work to be done in accordance with special provisions as hereby stated: G �i �� �n<, uCO�• �� ✓� APPROVED BY: DEPT. OF PUBLIC ORKS � ' �� /�����o-- 7' �G �� .� 11 wn i� � 5� l� B /-� G� tG K RPS �/ri�/ D''� /DATE (�� �S _ . 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 LAK� CiTY ENGINEER. 80 9�; � - � � ! � � �ua W -� � � ' � � � _� � � �� -� � .'� o T Z f� GO � � ! � � � �: ,� y N ;� � �: � e � � �, � r � � � � � � ; � �*�, � �e � � m ; a � � � `�,�. �: �, � Z � o � _ � � � � �. � � r �" _ � ' .. : � T f^ z m . rn m � � /\ ��� +� ,� \ o b � � D � �'o , � , y z � - m � � _, �t , i'� � � w — � . � . 3 • _� N �F � ► � 9 � � A P n t � E E, - � U '� : : � _ z E � . F v � � � �. « f� ro Z p �� p �° �' -� -� �y r �" ~ m � e T os :' O �"e . � ; n o '-P ; i � �'' ''3 � � , � :� " � � ��r► � � � �� �; P'� � � � � � � � � � S Z „ r ._ x � ' �, U �, � r ' � � �" M � m � � �97�rl; 1-1vP_ � � � � ,� � ' � `� °o � N , � � � �, � � _ , ; `��, a � : ��� � �-; � a �.� N � � � N N w, � � W � _ _. ° o s ++ N ` � . .�...� . . �. � � � . 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