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�INNES��P PERMIT MAY 13 ZU04
TO WORK WITHIN CITY PROPERTY/RIGHT-OF-WAY SEMENT�
AND
APPLICATION FOR INSTALLATION OF UTILITIES
1. Locat'ion °� % C I �1 U (i �i�� ���� �- �
A
2. Nature of Work ���� �� v� �� 1� /�' S C� � (` C�, •b' P
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 '
Tr�c Control Devices/Sigus or Privately owned _�
� Drainage Utilities
StructureBuildings Other �� t-U� �
4. Method of Installation or Consrtruction 0 ��.� � � � Q�..s ,,-�
5. Work to start on or after: �' 1�1 "�� and shall be completed by: �` a�• 0`� ` unless an extension
granted to: by: '
DATE STAFF/DATE •
6. Will detouring of tra�c be necessary? � C.� If necessary to detour trafFc, describe suggested
route: ' "
7. Provide with this application a copy of the contractors Public Liability Insurance.
DETOURS: The Director of Public VJorks shall be notified in wriring at least 72 hours in advance of
any detour being established, changed or discontinued.
NAME OF APPLICANT M' �`� �� c E5 �n W�� � ti1,� � S q��q ��� FHONE lo I o2 ��Q 3 c7 a��
PLEASE PRINT FAX 95 oZ' �� 6' -`� ���
ADDRESS y 0�O � � w, e�.� fE,�'� . r,'t�.t' C�.�C � '�-`�-.� 7 a+L
STREET CITY S ATE ZTP
NAME OF PARTY OR ORGAIIIZATION PERFORMING WORK �!h ��1 S K 4��( `� x� �
CONTACT PERSON: c � L. EMERGENCY (24 HR.) PHONE #: �c /02 -� c4a Q�
ADDRESS � f�b?C (� � �J ee41�� � 2. DAY PHONE
STREET � �'�'Y�� � � �( ST�TE ZIP�
� , �. �-� 7��
�:� LLr,dersigi�cu ,ercw;u, accc�,�s uic ici�li� atici wnuiiions oi uiis permit by tne c:ity of rrior 1.al:e as herein
nta ed an a I comply therewith to the satisfaction of the City of Prior Lake.
Signed: Title: �Q r� S�• �c� ��• Date: �� 3 Cj
EXFIIBITC.DOC PSa2 1 Of �
16200 Eagle Creek Ave. S.E., Prior Lake, Minnesota 55372-17I4 / Ph. (612) 447-4230 / Fax (612) 447-4245
AN EQUAL OPPORTUNIIY EblPLOYER
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 PERMIT
FINANCIAL SECURITY: AMOUNT: TYPE:
(Cash, Bond,
LOC, Etc.)
Fee: $ ���' � d Receipt No. Permit Na (J l� —(� �� r 3�J
LIABIILITY INSURANCE PROVIDED: (f`D7`c G�rl9►� C�.d,?n.aci✓ �(>� � MC-
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 af 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:
i��1� . �'z° °y
/DATE
ALL LEGAL REQUIREMENTS SHOWN ON PAGE ONE (1) AND ON ALL "SPECIAL PROVIStONS' SHALL BE COMPLIED
WITH. THE DATE WHEN WORK IS COMPLETED MUST BE REPORTED TO THE CITY OF PRIOR LAKE CITY ENGINEER.
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G:Udmin\FORMS1E7Cf3IBIT C APPLIC FOR INSTALL OF UTILITIES.doc
EXHIBIT "C"
TO
PRIOR LAKE PUBLIC WORKS DESIGN MANUAL
REGULATIONS PERTAINING TO THE INSTALLATION OR
REPAIR OF UNDERGROUND UTILITIES IN GITY STREETS
OR IN CITY RIGHT-OF-WAY/EASEMENTS
The following regulations and conditions constitute a part ofi the application made by any installer or contractor fior
the installation of utilities in any City street right-of-way or City utifity easement and the applicant, in making his
application to do such work, shall agree to abide by these regufations 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 promptiv notifv the Citv Enqineerinq Department 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 fumish, 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 instaifer or contractor of any of his legal
responsibilities or liabilities for the safety of the public.
4. All openings in 6ituminous surtaces shatl 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 exceed 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 than 95 percent of mod�ed Proctor density.
As soon as possible after backfill operations are completed, the cut bituminous edges of the trench shall be
painted with an asphalt emulsion such as SS-1. Immediately thereafter, the patching material shall be
placed and mechanical)y compacted to not less than 95 percent of mociified 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 Fiighway Department Spe�ifications 2331 be used.
T�c iiiiiS icu Si.ii iaGB �i i N � �i icfil t;Ul7iOfR1 IO if1E SUffaCe Oi fh@ llnqlStU('b6d fOadWBy.
No permanent asphalt patches shall be on any base whose temperature is 32 degrees Fahrenheit or less.
Cold weather patching shall be of temporary nature, using cold mixed asphalt, wel! graded crushed rock or
similar approved materials. Temporary patches shall be true to line and grade. Temporary patches shall
G: Wdmin�FORMS�EXHIBIT C APP[.IC FOR INS7ALL OF UTILIT[ES.doc
be replaced by permanent patches when weather conditions permit and not�cation shall be required as
stated in 2.
5. Other areas may be required to be compacted at the direcc�i�on 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 warning
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 existi�g 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 atl 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 fumish evidence of public liability insurance of not less than 5100,000/300,000 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 Ciry is named as an additional insured party.
11. Except for the negligent acts of the City, its agents and its employees, the perrnittee 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 Facifities — 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 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 disturbed, they shall be replaced in kind and
maintained satisfactorily until the turF is established.
� The undersigned hereby declares he/she has read and wilt comply with all the PERTINENT REGULATIONS as
stated above and relevant City Ordinances. f
GATE: � � 3 � � SIGNED: _
G:V+dmin�FORMS�E�7�IIBIT C APPLTC FOR INSTALL OF UTII..ITTeS•doc
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