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� r o �` PERMIT
��NNES �
TO WORK WITI�N CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS
AND
APPLIGATIQN FOR INSTALLATIQN OF UTILITIES
', 1. Location r / 3/ �M b, I� t� �
4
2. Nature of Work ��(��A C� #� A,� q�3 ��-
3. Indicate below items to be afFected and include a sketch or plan of work to be done.
Curb & Gutter Street Surface
, TraiUSidewal�: Trees:
Pond/Wetlancis (Publically owned '
Traffic Contrvl Devices/SignS or Privately owned _,
Drainage Utilities �
Structure/Buildings Other
4. Method of Installation or Consb. � Et u.9 ? �j �
, � .
5. Work to start on or after: � ��— . .
and shall be completed by: �� 5 � ` unless an extension
, granted to: b •
DATE STAFF/DATE .
6. Will detouring of traffic be necessary? _�� _, If necessary to detour traffic, describe suggested ,
route: , �
7. Provide with this application a copy of the contractor$ Public Liability Insurance.
DETOURS: The Director of Public Works shall be nfltified in writing at le��+ 72 hour in advance of
any detour being established, changed or discontinued.
NAME O� APPLICANT � 1 �/v� � � l��t � L L PHONE �o (c�' �G.3~ -�1�-� 'J
, PLEAS� PRINT FAX � °��i �o �0 4
.�vxESS � W1 � � � �. �e.,- � � � �• 5 � :' e � CX7 �r�� (,c� �c N1 � �` �
' STREET CITY STATE e 7
ZIP
NAME OF PARTY OR ORGAI�TIZA ' PERFOR,MING WOgI{ � l A S �C a�..( ��( (�
CONTACT PERSON: EMERGENCY (24 HR.) pgpNE �#; �� . �� � - (� • O (
aDnxESS �o � P���2, v� w:( o� R� � e.,r ��t �� � s�� - a 3 3• s� �r 7
TREET CITY STATE Zip ��
' ° � �oX t�S 557�.5
, i` � u�usi�iol - - �cepts tlie iei�nis biid cunuitions oi iiiis petmit by the C.;ity oi Yrior Lake as hereir►
, ntained d e to y co ply therewith to the satisfaction of the City of Prior Lake.
, Stgne Title: CE3��S� � �
Om,r � Date: * c� c�. - Q�-/
I r. •�( rZ; • ,�-iE r��
i E�itc.�oc ... e 1 of 4
I, 16200 Eagle Creek Ave. S.E., Prior Lake, Minnesota 55372-
, 1714 / Ph. (612) 447-4230 / Fa� (612) 447-4245
I ANEQUAL OPPORTUNITY EMPLOYER
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EXHlBIT "C"
TO
PRIOR LAKE PUBLIC WORKS DESIGN MANUAL '
PERMIT TO WORK WITHIN CITY PRORERTY RIGHT-OF-WAY/EASEMENTS
AND
APPLICATION FOR INSTALLATION O� UTILITIES '
PAGE 2 '
�
FOR CITY USE ONLY AUTHORIZATION OF PERMIT '
FINANCIAL SECURITY: _ AMOUNT: TYPE:
(Cash, Bond,
LOC, Etc.)
Fee: $ �s� �� Receipt No. � �S � Permit No. �D'O� � 71
LIABIILITY INSURANCE PROVIDED: ��1� I'�r��'sl�h�� ��o��'�ro�► Conne��v� �hC.
(n consideration of agreement to comply in all respects with the regulaqons of the City of Prior Lake covering such operations,
and pursuant to authorization duly given by said City af Prior Lake; permission' is hereby granted for the work to be done as
described in the above application, said worlc to be done in accordance with special provisions as hereby stated:
AFPROVED BY: DEPT. OF PUBLIC. WORKS
._ By; �� ��r/-Q�jl
� ' /DATE
_ .
ALL LEGAL REQUIREMENTS SHOWN ON PAGE ONE (1) AND ON ALL °SPEC,IAL PROVISIONS SHALL BE COMPLIED ' II
WITH. THE DATE WHEN WORK IS COMPLETED MUST BE REPORTED TO THE CITY OF PRIOR LAKE CITY ENGINEER.
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GUdmin�FORMS�EJ�IIgIT C A�puC FOR INSTALL OF U1'II1?ISS•dx . , �.
�XHIBIT "C"
TO
PRIOR LAKE PUBLIC WORKS DESIGN MANUAL
REGULATIONS PERTAINING TO THE INSTALLATION OR
REPAIR OF UNDERGROUND UTILITIES IN CITY STREETS
OR IN CITY RIGHT-OF-WAY/EASEMENTS
The foilowing regulations and conditions constitute a part of the application made by any installer or contractor for
the installation of utilities in any City street right-of-way or City utility easement and the applicant, in making his
application to do such work, shall agres to abide by these regulations and conditions:
1. The individual obtaining the permit shall, before commencing such work, notify the City Engineer when the
work at each location is to commence; and, when requested by the Engineer, shall submit plans and
specifications.
2. Upon completion of the proiect, the individual shall promatly notifv the Citv Enpineerin4 Department for final
ms�ection
3. The public is to be protected by the' individual, at all times, from the commencement of the work until the
completion and acceptance by the City. The installer or contractor shall so conduct his operations as to
cause the minimum inconvenience to the public. The installer or contractor shall fumish, erect, and
maintain, in accordance with the legally accepted standards, all necessary warning and traffic control signs,
barricades, traffic cones, and flashing tights to direct and control the movement of traffic through the project
in all directions and at all times.
The foregoing provisions shall not in any way relieve the installer or contractor of any of his legal
responsibilities or liabilities for the safety of the public.
' 4. All openings in bituminous surFaces shall be cut in a straight line with sides smooth and vertical. No ragged
edges will be permitted. Cutting shall be done with a concrete saw, cutting wheel, jack hammer, spades or
similar approved tools.
Backfill material shall be suitable for highway embankment construction. No peat, frozen lumps, broken
asphalt, sod, roots, or other undesirable material shall be permitted as backfill. Rocks larger than six
inches (6") in diameter shall not be used in backfilling of trenches.
The backfill material shall be placed in layers not to exceetl one foot (1') and mechanically compacted to
not less than 95 percent of modified Proctor density.
The upper six inches (6") of the backfill shall meet Minnesota Highway Department Specifications for Class
5 material and shall be compacted to not less fhan 95 percent of modified Proctor density.
As soon as possible after backfill operations are completed, the cut bituminous edges of the trench shall be
painted with an asphalt emulsian such as SS-1. Immediately thereafter, the patching material shall be
placed and mechanically compacted to not less than 95 percent of modified Proctor density. The asphaltic
material used in patching shall be of the sarne type as removed from the roadway, except, that in no case,
will a plant mixed asphalt of less quality than Minnesota Highway Department Spe�ificafions 2331 be used.
r~c ii �i� icu Siii ic,Gc ui i 1 iC �id`tl;l t�I ldll GC1f1fUfR1 IO IIIB SUffaCB Oi fh@ Uf1dISLU!'DeCI �03CIW8Y.
No permanent asphalt patches shall be on any base whose temperature is 32 degrees Fahrenheit or less.
Cold weather patching shall be af temporary nature, using cold mixed asphalt, well graded crushed rock or
similar approved materials. Temporary patches shall be true to line and grade. Temporary patches shall
.. G: C APPLTC FOR INS'tALL OF UTILTftES.doc
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be replaced by permanent patches when weather conditions permit and notification shall be required as
stated in 2.
5. Other areas may be required to be compacteri at the direction of the City Engineer.
6. Such permittee to be responsible for maintenance and �epair of all trenches for a period of one (1) year and
if settlement occurs or excavation caves in, the same shall be promptly indicated by adequate warning
signs and shall be restored to proper condition in accordance with speeifications above provided as soon
as conditions perrnit.
7. All culverts and ditches shall be replaced in their original position and condition existing prior to
construction and no change shall be made in drainage without approval of the City Engineer.
8. Permittee shall save the City harmless from all third party claims for injury or damage which may occur
between the time the work commences and the time it is finally accepted by the City.
9. The permittee may be required to jack or bore under certain streets, as determined by the City Engineer.
10. The applicant shall furnish evidence of public liability insurance of not less than $100,000/300,000 and
property damage of not less than $25,000 issued by an insurance�company authorized to do business in
the State of Minnesota on which the City is named as an additional insured party.
11. Except for the negligent acts of the City, its agents and its employees, the permittee shall assume all
liability for, and save the City, its agents and its employees, harmless and defend same at its sole cost and
expense ftom any and all claims for damages, actions or causes of action arising out of the work to be
done herein and the continuing uses by the permittee, including but not limited to the placing, constructing,
and reconstructing, maintaining, protecting and use of said facility under this application and permit for
construction.
12. Existing Facilities — The utility facility and installations shall not interfere with any existing utility facility on
the City's right-of-way or� easements. It is the responsibility of the applicant to �call for necessary locations
of existing utilities. (Gopher One)
13. Private Property — The work permit or permit for construction as issued does not in any way imply that the
appropriate easement exists to allow the applicant to work on private property.
14. Cutting Trees — The permission herein granted does not confer upon the permittee the right to cut, remove
or destroy trees or shrubbery within the legal limits of the right-of-way. Easements that are not specifica{ly
identified on the plan attached to this permit or relieve permittee from obtaining any consent otherwise
required from the owner of the property adjacent thereta
15. Clean-Up — Street, trailways and affected right-of-way shall be scraped clean at the end of each work day
and swept clean after construction is completed and left in a neat and presentable condition.
16. Replacement of Sod — Wherever top-soil and sod are disturbed, they shall be replaced in kind and
maintained satisfactorily until the turf is established.
The undersigned hereby declares he/she has read and will comply with all the PERTINENT REGULATIONS as
stated above and relevant City Ordinances. �
DATE: SIGNED: '
G:�pdmin�FORMS�H�IIB[T C APPLiC FOR INSTALL OF UTILIY7PS•doc
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