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�, PERMIT
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TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY/EASEMENTS
AND
APPLICATION FOR INSTALLATION OF UTILITIES
` � 5 ,� PE � . � �
1. T ocation � 5 " �
'' �o a d �.�``P C.EF LC �3 A t� � a TS L�
2. Nature of Work a r�
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
� Tra�c Control Devices/Signs or Privatoly owned � )
� Drainage � ' Utilities �
� StructureBuildings Other
4. 1Nlethod of Installation or Construction
��e � w.a�-' ��o � c- ,� �o `'`�
�� a" and shall be.completed by: � �o •' unless an extension
5. Work to start on or after: �.�.____
granted to:. -�'y ' � ,
DATE STAFF/DATE
6. Will detouring of traffic be necessary? � � If necessary to detour tir�c, describe suggested
route: � �
7. Provide with this application a copy of the contractors PublicLiability Insurance:
DETOURS: The Director of Public Works shall be *�fied in �=�riting at least 72 hours in advance of
any detour beirig established, changed or discontinued.
({F (� E � � M � + �A C:o,�. PHONE � � a • 8a3 • a a`g 3
NAME OF APPLICANT .� � FAx .
PLEASE PRIN
,� �J E. • �. S�} � � G � r1 � 3'� ? � ,
� ADDRESS l � � `� �� U n � � � ZIP
STREET CITY STATE
NAME OF PARTY OR ORGArdIZATION PERFOR�v1ING WORK L A �� ����8s � aR
CONTACT PERSON: � L- EMERGENCY (24 HR.) PHONE #: ys
ADDRESS �O� p'h R � � R a 6� I 8 S _ DAY PHONE ,
�jTy STATE ZIP �
� � :(ov� R�v'Lr� Nt�• S�S?`@S
, i , i;� u��el�i��� '•` ��GePts tlie tenr�s atici c�nuitions oi'tnis permit by the City or rrior 'Laice as herein
' ed and e to ful y therewith to the satisfaction of the City of Prior Lake.
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�'. 5 � P Date: � l`{ o S
Si,gned: e: � � s `
M,�C,� N«r�.
4aDe 1 of 4 44'i -4230 I'F ax �G121 44� -4245
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EXHIBIT "C'
TO
PRIOR LAKE PUBUC WORKS DESIGN MANUAL
PERMIT TO W�RK WITHIN CITY P�tOPERTIf RIGHT-OF-WAY/EASEMENTS
AND
�4PPltCAT10N FQR INSTALLATION OF UTILITIES
� PAGE 2
FOR CITY USE ONLY AUTHORIZATION OF PERMIT
FINANCIAL SECURITY: AMOUNT: TYPE:
(Cash, Bond,
LOE, Etc.)
Fee: $ �Sa<O(� Receipt No. /�� � Pemnit No. UP'�.S"' �a
.
LIABIIUTY INSURANCE PROVIDED: � 4/'r�S � y
In consider�tion of agreement to comply in all respects with the regulations of the City of Prior Lake covering such operation�,
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 accordance with special provisions as hereby stated:
APPROVED BY: DEPT. OF PUBLIC WORKS
By:
/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.
�:�PERMITS�ROW UtilRyUtOW PERMITS.9a
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