HomeMy WebLinkAbout5400 & 5388 Candy Cove Trl ROW Permit EXHIBIT "C"
PERMIT
TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS
AND
APPLICATION FOR INSTALLATION OF UTILITIES
l. Location �� '� `-� ��Dy CAYE,'TlU. SE �B � �"�'q"•5 �
2. Nature of Work RE W� gU�tE.p �H6NE. LIiJES '1D ACLAMOD 1�TE. IJEW tt9USE M" 5388 CAIJd�J COYE '�'IC SE
3. Tndicate be(�w item� t� be affected and ir.clude a sketch cr plan of work to be done.
�
Curb & Gutter Street Su�face
TraiUSidewalk Trees: �I
Pond/Wetlands (Publical�y owned
Traffic Control Devices/Signs or Privat�ly owned __)
Drainage Utilities '�,
StructureBuildings Other R.�W IF BLYD
—�.
4. Method of Installation or Construction �BLE 'ALOW -�WE.I�MP� GrDPHEt�.
5. Work to start on or after: S' ��' � 4 and shall be completed by: � D�V I ', unless an extension
granted to: by: ;
DATE STAFF/DATE ',
6. Will detouring oftraffic be necessary? N� If necessary to detour t�affic, describe suggested
route: -
I
7. Provide with this application a copy of the contractors Public Liability Insurance. I ��
DETOURS: The Director of Public Works shall be notified in writj� at le�st 72 ho�rs in advance of
any detour being established, changed or discontinued. '
NAME OF APPLICANT Z N� E. C��� T�.L C�� ����.- PHONE q S z- `�`�'�" S�'
PLEASE PRINT 'FAX qS2- 2ZLo - 3758
ADDRESS �+`�Q ����OD St. S�E� P�.1QP... LAIZ'£.. MN ' SS37Z-L�Z9�t
STREET CITY STATE i ZIP
NAME OF RARTY OR ORGANIZATION PERFORMING WORK !
CONTACT PERSON: �N aRR-��'E- EMERGENCY (24 HR.) PHONE #: �� Z' 91 °I - 5 8 Sl
ADDRESS DAY PHONE 'q52 2210 - 7O(�4
STREET CITY STATE ZIP I� -
ndersigned herewith accepts the terms and conditions of this permit by the C�ty of Prior Lake as herein
cont ' and to fully comply therewith to the satisfaction of the City of Prior T�ake.
Signe Title: �� � E�� Date: �- 5 � 4
i
'I
79 '
I
I
. �
�XHIBIT "C"
FOR CITY USE ONLY , : . AUTHORIZATION OF'PERMIT . _ �� ' ' .
.:. FINANCIA�; SEC�,JRITY:' ' : AMOUNT: :_.' TYPEc " . .,
(Cash, bond, LOC etc.)
Fee: $ ��— f��Z_ Receipt No. O �Z� fid ?ermit No. ��
LIABILITY INSURANCE PROVIDED: �l4 �/'v� /� (r /`�r e /'Uv�
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�n the above lpplication, said work to be done in accordance with special provisions as
hereby stated: �
APPROVED BY: DEPT. OF PUBLIC WORKS
. By: ��� � ��� y
� /DATE
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 LAKE CITY ENGINEER.
. 80
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