HomeMy WebLinkAboutCrossandra St, Itasca Ave, & Filmore Ave ROW Permit .. ,
EXHIBIT "C"
PERMIT
TO WORK W'ITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS
AND
APPLICATION FOR INSTALLATION OF UTILITIES
1. Location CROSSaNDRA ST, 8E'�Wti�N TCASCA aVE. t'�'ILMOItE AcVE. ���0'4''�4{a�
2. Nature of Work���EMEIJT 11F BUP.IED �lI�NE CA'SI.E DVCZO �A�1l.VRE. DF �1IC.lST11J�s �AC.IUTIES.
3. lndicate bel�w iTems to be affected and ir.�lude a sketch ar p(an 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 ELYD. - R�b.1 `
4. Method of Installation or Construction Y�►��"�A C:�PH�R. -. C�SI..E ?LbW
5. Work to start on or after: B �` and shall be completed by: � � ay 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 Liabiliry Insurance.
DETOURS: The Director of Public Works shall be no�ified in writjv,g at least 72 hours in advance of
any detour being established, changed or discontinued.
NAME OF APPLICANT = N����� ��L ��� �� PHONE a S Z-'`�47-37 SPa
PLEASE PRINT FAX 952- 2Z(e - 375�
ADDRESS �`�a ��R1�OD St. S�E� PI�1Ai� LAIZ'E. MN _ 55'S7Z-02
STREET CITY STATE ZIP
NAME OF PARTY OR ORGANIZATION PERFORMING WORK
CONTACT PERSON: �� $RR-��'�- EMERGENCY (24 HR) PHONE #: �� Z 9 � q " S a Bl
ADDRESS DAY PHONE q52' 2Z�°' �fl(�'p"
STREET CITY STATE ZIP -
T ersigned herewith accepts the terms and conditions of this permit by the City of Prior Lake as herein
conta d a to fully comply therewith to the satisfaction of the City of Prior Lake.
Signed. Title: �� �'� � EER-' Date: g ^ � � — � 4
79
t '
�XHIBIT "C"
. EOR CITY:USE iJNLY , , �, . , . AUTHORIZATION'O.F PERMIT-- ; . . � .,
FIIVA�IGiAL;SFCURITY: , . . . AMOLJNT'..� : . : : TY.PE: _. � i '
(Cash, bond, LOC etc.)
Fee: $ iSs Da Receipt No. ��577 �ermit No. ���
LIABILITY INSURANCE PROVIDED: ��'���'+/� �aG'l(h�v� .1r�f�rQnt.�
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 describesl,in th� above lpplication, said work to be done in accordance with special provisions as
hereby stated: '
APPROVED BY: DEPT. OE PUBLIC WORKS
. B �!�? - g �/ 7-av
� /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 LAK� C1TY ENGINEER.
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