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HomeMy WebLinkAboutLords St @ Quaker Trl ROW Permit � � �'OB # 0�-- �SZ� EXHIBIT "C" PERMIT TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS AND APPLICATION FOR INSTALLATION OF UTILITIES 1. Location LARDS ST. AT (3VAIC.ER 'TRL. 2. Nature of Work ��E ���� p��E ��-� ���Y1DE S6'RY�CE. TO WE.W ltOME AT MAAIITOU RD. A N L R.DS ST. �. Tndicat� below i±ems t� be affecred and ir.clude a sketch cr pl�? of work to be done. � Curb & Gutter Street Surface TraiUSidewalk Trees: Pond/Wetlands (Publically owned Traffic Control Devices/Signs or Privately owned _� Drainage Utilities Structure/Buildings Other $LYD. - R�W 4. Method of Installation or Construction pN�� ��HER - CA�I�- 4l-OW " 5. Work to start on or after: 9 '�` 04 and shall be completed by: � D�� unless an extension aranted 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: T'he Director of Public Works shall be ^^*�fP� �^ w*;r�ng at lPa�t 72 hours in advance of any detour being established, changed or discontinued. NAME OF APPLICANT Z N�EC'�R TEL EC� �'`.. PHONE 95 Z''�'�" 37St � PLEASE PRINT FAX q52- 2Z(o - 375E3 ADDRESS �q� ����� St. S�E� P�.1AR LAI�'� MN 553�Z-1�Z STREET CITY STATE ZIP NAME OF PARTY OR ORGANIZATION PERFORMING WORK CONTACT PERSON: �N $ A��G'� EMERGENCY (24 HR.) PHONE #: �( 2' 9 �°� ' S S 8'1 ADDRESS DAY PHONE Q52-' 22�° ' 7�(�4 STREET CITY STATE ZIP - The undersigned herewith accepts the terms and conditions of this permit by the City of Prior Lake as herein conta and to fully comply therewith to the satisfaction of the City of Prior Lake. Signed: Title: ���'���ER-' Date: q'�'� 79 �XHIBIT ��C" FOR CITY USE ONLY AUTHORIZATION'OF�pERM'IT ,.., , • � - FIN�XNCTAL �ECUR.FTY:' ' � ' , . R11�OUNT: ; , TYPE � � � (Cash, bond, LOC etc.) Fee: $ s0• C9C� Recei t No. ��� ']� P ��v���,, Permit No. �_— LIABILITY MSURANCE 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 as described'in the above lpplication, said work to be done in accordance with 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 WITH. 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