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HomeMy WebLinkAbout16502 Inguadona Beach Cir ROW Permit (3) - ���. ,�- I4 _� y'" � �. EXHIBIT "C" PERMIT TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS AND APPLICATION FOR INSTALLATION OF UTILITIES 1. Location �t�50Z IN&UA40NA SEALN CIT�.. SW ��''�3 � 2. Nature of Work REI.00A'TE EXITTINCs llt�lD�.GRAIIt�lO FAUl.IT1ES AT NAM�,OWWERS REOSJEST � IN CADT.DIALhT10R1 WITH XC�L EN�ts`� 3. Tndicate below items t� be affectad and ir�lude a sketch ar pl�? of work to be done. , F. , ". Curb & Gutter Street Surface T�aiUSidewaik • ° ' � : '�' . Trees: Pond/Wetlands (Publically owned Traffic Control Devices/Signs or Privately owned _� Drainage Utilities StructureBuildings Other K.�1h1 - 3l-V D ° � 4. Method of Installation or Construction $0.C.K N�E " 5. Work to start on or after: $'24 O 4 and shall be completed by: � D AY unless an extension granted to: by: DATE STAFF/DATE 6. Will detouring of traftic be necessary? N� 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 writinE at least 72 hours in advance of any detour being established, changed or discontinued. NAME OF APPLICANT Z N���a�R T E L E� Y� ��. PHONE `� S 2-- `�4?-37 Sf� PLEASE PRINT FAX 952- 2Z(o - 3758 ADDRESS 4fm�tD CGLGRI�OD st, S�E, P[�1UR. �AI�'E, MN 55372- L1Z9�i STREET CITY STATE ZIP NAME OF PARTY OR ORGANIZA"fION PERFORMING WORK 7rRDER f 4tlGrHSTI�AM. CONTACT PERSON: �N $ AR�v� EMERGENCY (24 HR.) PHONE #: � � Z- 91 q - 5�i g'1 ADDRESS DAY PHONE q'S 22Lc ' 7fl(�'q' STREET CITY STATE ZIP _ The undersigned herewith accepts the terms and conditions of this permit by the City of Prior Lake as herein co ' ed and agree to fully comply therewith to the satisfaction of the City of Prior Lake. Signe : Title: ���'����� Date: 5�17-04 79 , `" , EXHIBIT "C" FOR CITY USE ONLY .�1UTHORIZATION OF PERM�T •'..� FINANCIAL SECURITY: A�IOUN�T: -• " • TY�PE: �. . . . . . . , . . � . , . , . . . , , . . . , _ . . . . . . (C�sh, bond, LOC etc.) Fee: $ �` s �' � Receipt No. �� Permit No. "���YQ LIABILITY INSURANCE PROV[DED: �,Ag��v� ��`dd�GD'8h �AS� 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 descr.ibed in the above applicltion, said work to be done in accordance with speciai provisions as hereby stated: APPROVED BY: DEPT. OF PUBLIC WORKS . By: � J"���'t9 f/ /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� CITY ENGMEER. _:�.., ..,�, . ., ,..��.: , j . 80 : ffi � � r � � �� D o � � F , � ' m : O O � o �:: NEp ` .. .. . . . C � , .. .... . . . . � . � ;,� ; � ,�; , o oa i � ., ,. ; ,:. � ; ,. .,. .. . . + ; . .: � � , b YiF/ � . � � � � ��p, 6 i�✓�+ . ? �� � "�'°. W 2 , f � _ �� D , '^ � � . � .g � . .' � � � • � � . � � � � o� d • g � � : •., , , :,.,•. s �, _ ;:: . .., . , <:: � . . , � . _. _ , : , � � � �° � � � ��$+z "�+' i . � . �o � � 'v �`' _ E.W s S � � � 5*t . � � ��� � p� � ,,,,,„t, `. � , (J 4 . � t �.S ` t . Z � . . p . c t . � � d � •Aa � � � � A � eb � O s � � 3 � wei �wG .�: � ��� �j �� �, �� 3�..,.. � p �� �� W� �. �• � � M� w � b � R �0 6 � �., , : � "� � « �� 4 � g 3 � d �1 � ��"'� � . , ... !��{ .. . � � `t�s R' � . . n, '!.o- b b �> . ' � ((� . �- . . 4� � . a � a . � � � t4^� . � . . . . .. E . . .. . . . .. .. . . ' ' ' ' " ' ' � ' ' ' ' ' ' y � ' i:, '� i... -:+ .�', . 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