HomeMy WebLinkAboutEnclave @ Cleary Lake & Revere Way ROW Permit �� �--�'° "�`� c� - oq-o �
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PERMIT �
, TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS .
AND
APPLICATION FOR INSTALLATION OF UTILITIES
1. Location ��w DEYELOPMEI�JT -"T41E �lC1AVE AT CL�A�.Y LAk� "-(�EVER� W!l`1
2. Nature of Work PU+�.�.Nl�1JT 0� 'NE.YV ��tOWE �FaCI UTIES 1W �DIIJT UTIl,1TlES "T1C�'.1J�K .
3:; ��TAdiaaia�rel�w items to be affecred and ir.clude a �ketch cr nlar. of work to be done. -�
. � '�y . . � • .
Curb & Gutter '„�:, . t - Street Surface
f ,ti,.: ` :. a`� ,ti � _:.
TraiUSidewallc ' ''� ' Trees:
Pond/Wetlands (Publically owned
Traffic Control Devices/Signs or Privately owned _�
Drainage Utilities
StructureBuildings Other X SLV D `
4. Method of Installation or Construction �SkCK-H 0�. "
5. Work to start on or after: �' �" �� and shall be completed by: ' z w�KS unless an extension
granted to: by:
, � •; DATE 4 , STAFF/DATE
� _,.. .,.. . • <.
6. Will detouring of traffic be necessary? 1�10 1f 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 writing at least 72 hours in advance of
any detour being established, changed or discont�rued.
. NAME OF APPLICANT =N T�.C��,R TE.LE�.� Y�'�... PHONE `�SZ
PLEASE PRINT FAX `�S2 22.(0 - 375f3 �
ADDRESS '`� CdtiDRi4b8 St. S�E. PR1Ai�. LAl2'E, MN 553�Z AZ.°1`1
STREET CITY STATE ZIP
NAME OF PARTY OR ORGANIZATION PERFORMING WORK
CONTACT PERSON: �N $AR���- EMERGENCY (24 HR.) PHONE #: �� Z 9 � g ' S 9 6l
ADDRESS ' DAY PHONE q52- 2Z(v - 7fllc+4
STREET ' CITY STATE ZIP _
The undersigned herewith accepts the terms and conditions of this permit by the City of Prior Lake as herein
. contained and agree to fully comply therewith to the satisfaction of the City of Priar Lake.
-�-�'121 t,t.,ot- �1.1 t31 N E ER... S' I In -O lo
Signed: s`�-�1 Titte: Date:
79
, ,
�XHIBIT "C"
FOR CITY USE ONLY AIJTHORIZATION .OP PERMIT
FMANCIAL,SECURITY: Aiv10UNT: TYRE:
(Cash, bond, LOC etc.)
� --� � • �.•�17
Fee: $ Receipt No. Permit No.
LIABILITY INSURANCE PROV[DED: S�►�I�� ��f1i�G�
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 describeci in tlie above application, said work to be done in accordance with speciai provisions as
hereby stated: ,
APPROVED BY: DEPT. OF PUBLIC WORKS
� BY; `� 8'S-D6
' ' /DATE
ALL LEGAL REQUIREMENTS SHOWN ON PAGE ONE (I) ANQ ON ALL "SPECIAL PROVISIONS" SHALL
BE COMPLIED WITH. TI-lE DATE WHEN WORK IS COMPLETED MUST B� REPORTED TO THE CITY
OF PRIOR LAKE C?TY ENGMEER.
80
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