HomeMy WebLinkAbout5965 150th St ROW Permit ,
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� N E S D � Q' PERMIT
TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS
AND
APPLICATION FOR INSTALLATION OF UTILITIES
1. Locafion �1 `� S � S ��� C5 T.
4
2. Nature of Work T'� C_� �-� C�c � 1�� ���- �
3. Indicate below items to be affected and include a sketch or plan 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 �� tx.� :
4. Method of Installation or Construction ���...�
5. Work to start on or after: � � and shall be completed by: � �-��� unless an extension
granted to: by: � `
DATE STAFF/DATE •
6. �11 detouring `of traffic be necessary? d 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 notified in writing at teast 7� hours in advance of
any detour being established, changed or discontinued.
NAME OF APPLICANT M• �- � A E'_ I J�• I� �. t@.✓ pgp� � �a •� 4 3- aa °� 3
PLEASE PRINT FAX �Ija ��-9 rv �O
�DxESS I�( �(o a- C'm ..�. r�• �..r c.. e� T e r'� ar �.a M� SS" 3?-�
STREET CITY STATE � ZIP
NAME OF PARTY O�t ORG ZATION PERFORMING WORK N��_ �5 � CC� ,
CONTACT PERSOI� �S ✓ EM�tGENCY(�4 HR.) PHONE #: �= S� - '7 a g
ADDRESS � O 1't � OcJ /t'�� MN DAYPHONE
STREET CITY STATE ZIP
+ ss�gs
- uciSigii'' -- ""u`i aGGcyis uie i�iTiis niiii cunuiiions oi mis permit by the City oi Yrior Lake as heretn
contaiaed and comply therewith to the satisfaction of the City of Prior Lake.
Signed: Title: � S � Date: �
EXI-IffiITC.DOC Page 1 of 4
16200 Eagle Creek Ave. S.E., Prior Lake, Minnesota 55372-171� / Ph. (612) 447-4230 / Fax (612) 447-4245
AY EQUAL OPPORTUNITY EblPLOYER
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EXHIBIT "C"
TO
PRIOR LAKE PUBLIC WORKS DESIGN MANUAL
PERMIT TO WORK WITHIN CITY PROPERTY RIGHT-OF WAY/EASEMENTS
AND
APPLICATION FOR INSTALLATION OF UTILITIES
PAGE 2
;
FOR CITY USE ONLY AUTHORIZATION OF P�RMIT
FINANCIAL SECURITY: AMOUNT: TYPE:
(Cash, Bond,
LOC, Etc.)
�� UP"o�f - 2y'
Fee: $ 2 ��' r Receipt No. � g�' � 9 Permit No.
LIABIILITY INSURANCE PROVIDED: �T�""`' E'�'�►FZR�S A'C��1 Gy , � JJ C.
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 Ciry of Prior Lake; permission is hereby granted for the work to be done as
described in the above applica6on, said work to be done in accordance with special provisions as hereby stated: �
��2r�t � r vOES No� Av �2 i Z.E G�o�2K �! FFEt 7 G C N�3 f
� TT�� STR�E % Sw?FAcE , APPROVED BY: DEPT. OF PUBLfC WORKS
� .. - _8-ay
ND/e /1 SIDG�.vAt-K _ gY�
/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 LAKE CITY ENGINEER.
�
G:\Admin\FORMS�EXfIIHIT C APPLIC FOR INSTALL OF UTILTTIES�doc
_.� ..
EXHIBIT "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 following 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 agree 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. U on com letion of the ro"ect the individual shall rom tl notif the Cit En ineerin De artment for final
inspection.
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 furnish, erect, and
maintain, in accordance with the legally accepted standards, all necessary warning and traffic control signs,
barricades, traffic cones, and flashing lights 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 toois.
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.
Th� backfill material shall be placed in layers not to exceed one foot (1') and mechanically compacted to
not less than 95 percent of mod�ed 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 than 95 percent of modified Proctor densify.
As soon as possible after backfill operations are completed, the cut bituminous edges of the trench shal! be
painfed witFi an asphalt emulsion such as SS-1. Immediately thereafter, the patching material shall be
placed and mechanically compacted to not less than 95 percenf 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 r;�;x�u asphalt Gf iess quality than Minnesota Highway Deparfinent Specifications 2331 be used.
T4.., r:..,:..6....t _....t..-- —r a� _ _
���� ��� ���� �cu aw �a�c vi u�C �,aici, si �d;i conForm io ine suRaee or ihe unciisturbed roadway.
No permanent asphalt patches shall be on any base whose temperature is 32 degrees Fahrenheit or less.
Cold weaiher patching shali be of temporary nature, using cold mixed asphalt, welf graded crushe� rock or
similar approved materials. Temporary patches shall be true to line and grade. Temporary patches shall
G: WdminIFORMSIEXHIBIT C APPLIC FOR WSTALL OF UTILITIES.doc
. +�,_
be replaced by permanent patches when weather conditions permit and notfication shall be required as
stated in 2.
5. Other areas may be required to be compacted at the direction of the City Engineer.
6. Such permittee to be responsible for maintenance and repair 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 waming
signs and shall be restored to proper condition in accordance with specifications above provided as soon
as conditions permit.
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 $100,000/300,00 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 from 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. ft is the responsibility of the appl'icant to �call iar necessary locations
of existing utilities. (Gopher One)
13. Private Property — The work permit or permit for construction as issued does not in any way impty that the
appropriate easement exists to allow the app(icant 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 specifically
identified on the plan attached to this permit or relieve permittee from obtaining any consent otherwise
required from the owner of the property adjacent thereto.
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 di�turbed, 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 REGULATfONS as
stated above and relevant City Ordinances. �
� a '{ � SIGNED:
DATE:
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