HomeMy WebLinkAboutVillage Lake Dr, Tower St, & Toront Ave ROW Permit �� � •-
�f �
EXHIBIT "C"
PERMIT
TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS �
AND
APPLICATION FOR INSTALLATION OF UTILITIES
1. Location U1LL/�GF L/�KE DRII/�, TO[UEK ST. TDRDIUTO /aOIE �•��p
2. NatureofWork BLOLU FZBER THl2I.� EX.�.STIIVG- DUGT AtUD PLA�E NL-LU DLtLT
CABLE� t1N/D HAN17 !�/�LL.S' AS St1DtUtV ��Y A7TR!',H£l� SKETGH
3. Tndicate beiow items to be affecred and include a sketch ar plsn 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 `
4. Method of Installation or Construction BORL• AN1� �L c.�w. caa�.E a��.eT -�Lew F18ER.
5. Work to start on or after: S and shall be completed by: ��EE� uniess an extensio�
granted to: by:
DATE STAFF/DATE
6. Will detouring of traffic be necessary? ND If necessary to detour traffic, describe suggested
route:
7. Provide with this application a copy of the contractors Pubiic 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 discontinued.
NAME OF APPLICANT Z N� E C� [`�..R ��L Gl� ����... PHONE � 5 Z' `��" S�
PLEASE PRINT FAX 952- 2Zto - 375�a
ADDRESS '�`�� ��Rt'�Ob St. S�E� PC�I�R. LA{�� MN 5537Z- L]Z9�t
STREET CITY STATE ZIP
NAME OF PARTY OR ORGANIZATION PERFORMING WORK
CONTACT PERSON: �� gA���'E- EMERGENCY (24 HR.) PHONE #: � � Z' 9 �°� ' S t� 8l
ADDRESS DAY PHONE q52-' ZZj°' 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
conta' an e to fully comply therewith to the satisfaction of the City of Prior Lake.
Signe . Title: �� �'� N �ER-' Date: � �' � � � � �
79
�XHIBIT "C"
. FOR CITY USE ONLY AUTHORIZATION OF PERMIT
FINANCIAL SECURITY: AMOUNT: TYPE:
(Cash, bond, LOC etc.)
Fee: � ��7�C9� Receipt No. � / Permit Na �C9 '�
LIABILITY INSURANCE PROVIDED: lJ/'9T%'v� /�/�� l[ �- -�y1S'l�rCi�GP
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 described in the above application, said work to be done in nccordance with specia! provisions as
hereby stated:
APPROVED BY: DEPT. OF PUBLIC WORKS
� sy: �� � 'y��G- �
/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 LAKE CITY ENGiNEER.
, 80
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