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HomeMy WebLinkAbout2009-08-21 Right-of-Way Permit City of Oak Park Heights RIGHT-OF-WAY PERMIT FORM CITY PERMIT NO. : 20 - PERMIT FEE: minimum $150.00 COMPANY PERMIT NO. : DATE: APPLICANT INFORMATION: DEVELOPMENT/ ADDITION / LOCATION DESCRIPTION OR. SITE ADDRESS: 7 9,5- /41orutii h, DoUt AVe N OWNER (Applicant) : (101-1.(7 4.6 UTILITY COMPANY: CO3-A.C`_Q -I- CONTACT PERSON: K-e / (JN Q �), TELEPHONE NO: (,SI -2 5S= l 90 7 ADDRESS: 97 OS b O 1"A.. Pa.r K CITY: ( V1 C.+11 7 1r CL STATE: 101 ZIP CODE: 5S3�J CONTRACTOR INFORMATION: /� CONTRACTOR PERFORMING WORK: U IAA U c rs e ( Se r u r C.e CONTRACT NAME: D(�V► ACAr f Ulu,. CONTRACT NUMBER: 612_ 3/28PHONE�J aZ CONTRACTOR PERFORMING WORK MUST ATTACH CURRENT CERTIFCATE OF INSUARCE NAMING THE CITY AS AN ADDITIONALLY INSURED AND IN AN AMOUNT NOT LESS THAN $1,000,000. WITHOUT SUCH PROOF OF INSURANCE NO PERMIT WILL HE ISSUED. TYPETYOF WORK : r1NEW PRIVATE UTILITY IL�JREPLACE/REPAIR LCOMMERCIAL DRIVEWAY APRON (WIDTH?) feet LJ I RESIDENTIAL DRIVEWAY APRON (WIDTH?) feet CONNECTION TO CITY SYSTEM (REQUIRES PREPAYMENT OF ACCESS FEES) : EkATERMAIN ❑STORM SEWER ❑SANITARY SEWER 00THER WHAT THE WORK WILL INVOLVE (REQUIRES SECURITY TO PROTECT INFRASTRUCTURE / COMPLETE RESTORATION. Complex plans may incur additional costs for mitigation plan review and inspections. Must include erosion control, protective measures, and restoration plans - all new utilities must be fully located for future GSOC requirements): Tp as ov 1 ca-fcS )STR T PEN CUT (requires ppro ed plan with access, traffic control, and inspected full width restoration - security required) ❑PATHWAY CUT (requires approved plan with full width restoration and security for restoration) 1XCAVATION IN BOULEVARD or CITY OWNED PROPERTY (requires approved plan and security for restoration) Lrili•.O.W. ACCESS (requires approved plan on use, control, mitigation and restoration. Must have full marking of new utilities) EXPLANATION OF WORK / ADDITIONAL COMMENTS: AUG 2 12000 b.rec4tc.mcd Ea re Across 38-h St ev fr-o exi5�ihf led Qvl marl-LA Sidccr1 S-I-r'c + 0 1-11 5oQ-4 Sick, (-ye- Cctavc +LA %s /oca-he-0J {e, Lg. surc (Ae. (U J,o't aL,c_ fie a pen cut koc.d. PROPOSED START DATE: U..)lq{v p-c rLA- • PROPOSED END DATE: Go bc.Y S Applicant agrees to abide by and follow all applicable ordinances, laws, rules, and regulations of all regulatory bodies, including but not limited to city, county, state or federal regulatory agencies. Applicant acknowledges that placement of its utilities in any Right-of-way is subject to the rights and rules of the City Of Oak Park Heights. Damage, loss or destruction of applicant's facilities and/or its resulting business interruption will not be restored, compensated or reimbursed by the City in the event the City needs to remove, relocate or terminate such facilities while accessing its utility services in the area for any reason. Private utility locates are required by the owner and/or applicant for the utility in the Right-of-way and in perpetuity. The Applicant shall provide, at its sole expense, full "as-built" drawings for all infrastructure installed in the City Right-of- way. All "as-built" drawings shall be completed by a licensed Minnesota Engineer or Surveyor. "As-builts" shall be provided in paper and digital form acceptable to the City of Oak Park Heights including GPS coordinates in the Washington County Coordinate system. The City additionally reserves the right to remove and/or deactivate any and all installed infrastructure placed in its Right-of-way should these "as-builts" not be provided or should these prove inaccurate. The Applicant accepts in perpetuity the responsibility to perform at its expense all necessary locates (Gopher State One Calls) that may arise or be requested in the future by the City or other parties. The Applicant does release and hold harmless the City from any and all responsibility for utility / service locates. APPLICANT SIGNATURE - by your signature you accept and agree to all conditions as stated above. Must be signed by owner, president or CEO of firm installing utilities. • Name /4/11 el, r-1 Title Cr>>NiM c rrr f 6,1 C C7Ci u-01 () / , Signature 401r Date: -"'" 17 -,2G0 1 Phone # : ( -- ?S-S-- - I , 0 -2 TO BE COMPLETED BY CITY PERMIT EXPIRATION DATE: Q 30 - d 1l SECURITY ESCROW AMOUNT REQUIRED: $ HAS PROOF IOF INSURANCE BEEN SUPPLIED? \.(1e5 TYPE OF FINAN AL SECURITY: ASH/CHECK EIANNUAL APPROVAL" SIGNATURE : TITLE : DATE : .' / .-- 4 Ot. 1.--ft ' 7- / - 07 . ....., _. o et4/4c. (HA s 7 N.4... N/ ......,-\NN/ 13-4 X 111 1-- a , z / N '99 I", /C / . e / c• 1, Emil 2 el, / IIP 'al - RT. , �a /. - 117PLI1!' ' ■N N N O^ / / ://,' / S • / c ' ^l›, .(J' 01 "I,, /' J` ,pc p ./ •OM,,// / ` 41,co Eo� �`Z, l -es /, qi,. cb J , . 8. • `, ) • 0 L..1-d CD 0 .0, , 5-,, � N. . . 7, .. z / o� :°:i© / D i r5. / (5. y� U!— oo� � _J1..1_ $Zoo / / n4'vR3+ / / NW000h / W dcio* / / ^� °%y �NC�yN� f , / / O '? In (31(b ' / 2 / TA /cb / / / / / A'41 ►,,< / NO / y N / ' /' ``� d °• / / ° '. / / ‘90,. / / / ` / / I=J (?)21 // bo/' cbb 0Z / // / / / ' cb 0� / / / / 2 / ' / 04 / © 0, ' . / / N N 44\t• N ‘_ -I- N/ . :.,:il':...t.,.71 c.,,;: f 1 n l / ,-".s ..4n. . o \ // 9 . ,":-,'.'77-;;,tes:.4"..--'!..'f- , �j� / tn N 111.:... koc:i lc- •. Ns, ''''::::.:(411; , / Q , ....„..„,,,, ....., -,1, ,,, Ilr° ,////,/"///:/ ' . --\--- .k...1,-, ,, r i E. . ilk iii -4 F.' // / 2// // / i‘,/..):-.'P h / �f �- / / \ / l - - N / r°- ---- -a iaw-Aeym i> / / y � n U s N / T �`� /O� Q •/ ®9/ / � l ' mss" •,..... v\O`�� -' nO• // / \ . O (i) v/ / .Q :1-' '' '...i /OS �- _x_,_,..swo uA v._ , (..) in V / O • / 0 $1111 s. •:.'1' kW.E.kir-':J L.: „0.,,._. ,,c '1) / G.* ,.. :. .„._ ......4.,.,.. .i., , „1 , Wst4,44, , Cr) / I 0, �„ ,. ... / / S `/6/L., 4> U1--- CD 0 ,.-mill -:,. ILL Q • 00 �w / ';EJ / / y Q M N N / o 0 0 / Q(16/ w 000 t.:,‘ vi / 4114 V) N N N� ' / oven ,(._;, / i 05,1 (lc1 / ', SI// / r / Ai ii I p t:= / '' ,. / / ofQ/ ;D •0 / / 1 / / ' / / / • '` F— r co o / , / I . / ' \ /c-‘1] d .6) / / ' CO U) tet\ T M cu r / / / // Gil) , / �{' / .,./ •,-- Y N . ,,,,\" /".411 ' .. // I I- 0 NN --94.9 4 1 7 C- .- CD CO rh //: , . 11 , - momme. ,,/ ' r-losi ,"/ , // /' N`ss< 1 Atilt , , a s9 a mom /� , , • �ldf 0� o./ /44,,Cn E 1 -6'04f/': ) '9'91 • . ►, .., ) ` N ID ZZ I / U I—IX i / o'oo�l�"t , Nr- 91 ,'/ / %/ 4211-1 d1ti oval qb / / / / / r4 r , - /, IN. 41,.. -f y,. • II , / . J., / / '9 ...., / / / / / , / / / , / w1gv / , , / , , GI N. / , , N. (\o0. ,© ACORD,. CERTIFICATE F LIABILITY INSURANCI op ID Sc DATE(111NODIW Y) PRODUCER UNIVE-2 08/18/09 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Faribo Ins-Hastings Branch HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 1303 S. Frontage Suite 4 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hastings MN 55033 Phone:651-319-0613 Fax:651-319-0624 INSURERSAFFORDINGCOVERAGE NAIC; INSURED INSURERA Nest Bend Mutual 15350 $SURER B Universal Services Inc INSURER C 660 Hale Ave No #240 INSURER Oakdale MN 55128 INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TD TE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERMOR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WINCH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGREGATE LIARS SHOWNMAY HAVE BEEN REDUCED BY PAD CLAIMS RT LItWL POLUCYEi TAE YEXPYTATRfR - MSRC TYPE OF INSURANCE POLICY NUMBERDATE(MWDWYY) DATE DAWOO(YY) Lain GENERAL LIABILITY EACH OCCURRENCE $1000000 A X COISERCAL GENERAL LABILDY BCN1075023 02/19/09 02/19/10jE.`N lRorr ) $100000 _ CLANS MADE®OCCUR MED EXP(Any WNpreln) $5000 X $100 PD DEDUCT PERBONALIADVINARY $1000000 GENERILADGIEGATE $2000000 GENL AGGREGATE LYT APPLES PER PRoouCTS-COUP/Or AGG $2000000 -1 POLICY n n LOC AUTOMOBILE LA9UTY COMBNEO SINGLE"ST f 10000 OO X X ANY AUTO BCN1075023 02/19/09 02/19/10 ALL OWNED AUTOS ----- --BODILY INJURY $ SCHEDULED AUTOS NW Peron) -- HIRED AUTOS BODILY"MIRY NON-OPINED AUTOS (Ps A WEIIM) PROPERTY DAMAGE $ (Per ambit) WAGE MOLT' AUTO OILY-EAACCDE/TT $ ANY AUTO OTHER THAR FA ACC I AUTO ONLY_ AGG EXCEIIIIRRIBRELUIAINRLRY EACHOCcwENCE 15000000 _ AOCCUR E CIANAU MADE CUN1075025 02/19/09 02/19/10 AGm+EGATE $5000000 _ _ _s DEDUCTIBLE $ X RETENTION SWAIVED $ EMPLOYERS MPLOYMINDERS SLI LIABILITY COMPENSATION AND X ITOTTY TIMMTS I {O ER A NIT RS Esu R/PAR MCN1075024 02/19/09 02/19/10 ELEACHACCDENT $500000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? EL DISEASE-EA EMPLOYEE$500000 If yes,dDBO ID under SPECIAL PROVISIONS below ELDIEASE-POLICY LIST $500000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSENENT I SPECIAL PROVISIONS THIS CERTIFICATE OR MEMORANDUM OF INSURANCE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE INSURANCE POLICY. SECTION 60A.39 OF THE MINNESOTA STATE INSURANCE CODE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE RIURG INSURER WILL ENDEAVOR To NAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAKED TO THE LEFT,BUT FAILURE TO DO SO SHALL City of Oak Park Heights IMPOSE NO OHIGATI N OR LABLITYOF ANY HIND UPON THE R,INSUREITS AGENTS OR 14168 Oak Park Blvd No Oak Park Heights MN 55082 REPRESENTATIVESRIXEBI AUTHORIZED REPRISE-TATA Susan G Mo11 ACORD 25(2001/081 D ACORD CORPORATIOO N 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001108)