HomeMy WebLinkAboutToronto Ave @ Tower St ROW Permit ,f
EXHIBIT "C"
PERMIT
TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS
AND
APPLICATION FOR INSTALLATION OF UTILITIES
1. Location rnRONra RvE, �r �tar�►� sT. 3 #� �-037 �
CKtk. OS29 ! `l
2. Nature of Work PLAG6ME1�1T AF 3URtE,D �ft�NE CJk.BLE
3. indicate below items to be aff�ctad and in�lude a.wketch ar plan of work to be done.
,
Curb & Gutter Street Surface
TraiUSidewalk � Trees:
Pond/Wetlands (Publically owned
Traffic Control Devices/Signs or Privately owned _�
Drainage Urilities
StructureBuildings Other R!W ` BIND �
4. Method of Installation or Construction �� �-�w "
5. Work to start on or after: 7' 19 � 0 4 and shall be completed by: ��� �- 0 4 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 contractots Public Liability Insurance.
DETOURS: The Director of Public Works shall be notified in writine at teast 72 hours in advance of
any detour being established, changed or discontinued
NAME OF APPLICANT Z N����� T�.L�C�.� ��. pgp� R$Z
PLEASE PR1NT FAX q52` 22.l0 - 375f�
ADDRESS �`�a ����� �♦, s►E� P�QR- Lpl��. MN 5S'S7Z-bZ9Gt
STREET CITY STATE ZIP
NAME OF PARTY OR ORGANIZATION PERFORMING WORK
CONTACT PERSON: m'N $ A��v�- EMERGENCY (24 HR.) PHONE #: �! 2- 91 °I - S 8 B'1
ADDRESS DAY PHONE Q52- 2'LLo - 7OGo4
STREET CITY STATE ZIP _
The undersigned herewith accepts the terms and conditions of this permit by the City of Prior Lake as herein
cont 'ne d o fully comply therewith to the satisfaction of the City of Prior Lake.
Signe Title: �����EE� Date: �"Z-$`
79
/ � � �
�XHIBTT "C"
FOR CIT`Y. USE ONL' Y. . AUTHORIZATION Or PERMIT .�,
FINANCIAL SECURITY: =� AMOLlNT: � TYPE: �
(Cash, bond, LOC etc.)
Fee: $ � �t�-(� a Receipt No. �� ?ermit No. ' �
LIABILITY INSURANCE PROViDED: �v/'�►�� /n► �✓1S!/f�gGG
[n 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
B ��'1 � 7'- G -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 LAKB C?TY ENGINEER.
80
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