HomeMy WebLinkAbout16502 Inguadona Beach Cir ROW Permit (3) - ���. ,�- I4 _� y'"
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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.
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