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HomeMy WebLinkAbout17483 Sunset Trl . � EXHIBIT "C" PERMIT TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS AND APPLICATION FOR INSTALLATION OF UTILITIES 1. Location � 7483 SUNSET TRI. sw - ro suNriay c.�tt. . SD� # 04 O�k4 P 2. Nature of Work Y�E '�VR.IED PFl01�lE. CABI.E I1J f,AST '1��W af SUN SE.T TRI. 3. lndicat� bel�w items to be affec�ed and ir.�lude a sket�h ar plar_ of work to be done. Curb & Gutter Street Surface TraiUSidewalk Trees: Pond/Wetlands (Publically owned Traffic Control Devices/Signs or Privately owned _) Drainage Utilities StructureBuildings Other IC�1�1 - BLV D.` 4. Method of Installation or Construction �g� �'�-�� 5. Work to start on or after: 8 "«'� y' and shall be completed by: � �A� unless an extension granted to: by: DATE STAFF/DATE 6. Will detouring of traffic be necessary? � b If necessary to detour traffic, describe suggested route: 7. Provide with this application a copy of the contractors Public Liability Insurance. DETOURS: The Director of Public Works shall be notified in writing at least 72 hours in advance of any detour being established, changed or discontinued. NAME OF APPLICANT = N����PA. �Ti �L �C�..� ���..- PHONE Q S Z-- `�47-37 S� PLEASE PRiNT FAX 952- 22.l0 - 3756 ADDRESS �`�Q ��RI�OD St. S�E.� �dOR. LA1Z� MN 553�Z-L�Z STREET CITY STATE ZIP NAME OF PARTY OR ORGANIZATION PERFORMING WORK CONTACT PERSON: �N BARL�GE EMERGENCY (24 HR.) PHONE #: �� Z 9 � q ' S S a7 ADDRESS DAY PHONE q52' 221° ' 7flk'q' STREET CITY STATE ZIP - The undersigned herewith accepts the terms and conditions of this permit by the City of Prior Lake as herein cont an ee to fully comply therewith to the satisfaction of the City of Prior Lake. Signe • Title: ���'���`�� Date: 8 79 i i �XHIBIT "C" FOR �iTY USE ONLY . � . , .: AiJTHORi�A'F(ON OF. P�RM�T , �, .. FINANCIA�, SECURI�TY: � � , • , AMQUNT:� - TYPE: . � (Cash, bond, LOC etc.) Fee: $�s�• � d Receipt No. (��� Permit No. '� "�,5� LIABILITY INSUIZANCE PROVIDED: � 1'�v�i( /O�rp�(o(lL�jv� 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 us described in the above lpplication, said work to be done in accordance with special provisions as hereby stated: ' i i � . APPROVED BY: DEPT. OF PUBLIC WORKS . � By: ��� � oy ,, ` �• /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 LAK� CITY ENGMEER. . 80 m � � m � � b LI O ? 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