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. THE DATE WHEN WORK 1S COMPLETED MUST BE REPORTED TO THE CITY
OF PRIOR LAKF CITY ENGINEER.
. 80
M
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