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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. . , � . 80 . - m O � � � m a c� o �p o ' � O � � � m I p � � E � � � � � � � � � G Z — � � � ITASLA AVE SE. ; ' 7 '� 7 i � � D '' 1 � � . � �...:, � N ,N � � � 9 � � � ' r 'R — � G W � � � � � � � 0 f � � � � � �g s v a 11 � n � r � x � � z � � � o �— 7° � —N i ''' �y g � � � IL2Zl IL� 197 c� � fA s o 0 � TI In p � � x � � m � ; � d � � ,� � r � n N �n m N , D -�' a r m � o � a w ' � � t}+ y ' � . .+1 N � � I � � � e � • � 'L Q ; � j I ,A � o � � � � o L GA .y e i .0 C � �o � a T � � �j �.{ lY � v�N � � °� O l's' �w �, � W �g x � � � !'T = C�' _ � Y y < D r x . z � ymOCD te' Iblq� � ?° 'O��O� �IN� A m 7�0 �zm� � U«i� o 'i � v � 7 � � � Z D t�+ m m �n ..� Z fA � � 1 f n -i � -F N A m � � � � � � L v m FILMORE AVE. SE � S� � = o � v n e � � s -� n w d r � -�.1 � i Z . , 't� �' �'�,v � i��`�".�E. 1"�/ ',..' ,� co,�-�. � � YIMf��M �� WrypWO�� . 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