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HomeMy WebLinkAbout2009-08-17 Right of Way Permit Permit City of Oak Park Heights AUG 1 7 2009 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: 01-113l i OWNER (Applicant) : ( 01,1f"4"-Y/ v:( / IVk4.L: 1'C� UTILITY COMPANY: ,(,J1- CONTACT PERSON: \NYI TELEPHONE NO:'1).''LIAO` Cit O ADDRESS: \NYTK 5161 CITY: '4ln O STATE:�f (ZIP CODE: f��� CONTRACTOR ORMATION: CONTRACTOR PERFORMING WORK: 'Y �.e.„ CONTRACT NAME: CONTRACT NUMBER: PHONE: 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 BE ISSUED. TYPE OF WORK : TY LJNEW PRIVATE UTILITY L'JREPLACE/REPAIR ❑OCOMMERCIAL DRIVEWAY APRON (WIDTH?) . feet l (RESIDENTIAL DRIVEWAY APRON (WIDTH?) feet CONNECTION TO CITY SYSTEM (REQUIRES PREPAYMENT OF ACCESS FEES): CO LJWATERMAIN ❑STORM SEWER ❑SANITARY SEWER EITHER 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) : STREET OPEN CUT (requires approved 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) ❑EXCAVATION IN BOULEVARD or CITY OWNED PROPERTY (requires approved plan and security for restoration) ©R.O.W. ACCESS (requires approved plan on use, control, mitigation and restoration. Must have full marking of new utilities) EXPLANATION OF WORK / ADDITIONAL COMMENTS: 41(' bi th ---(ti ph(31(vi , wirL 1,tY1 pr 1 wI-. arvi I O\r12- (f- c-wvvn in PROPOSED START DATE: of -o PROPOSED END DATE: YJC1 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 r 1 Title Signature Ohl tat Date: S• I14 ,bC1 Phone #: lc Q ,4cE 07c TO BE COMPLETED BY ,CITY PERMIT EXPIRATION DATE: 9 / +-1 /0 a SECURITY ESCROW AMOUNT REQUIRED: $ HAS PROOF IOF INSURANCE BEEN SUPPLIED? d� A- � � � �5 - C`C"p �` 4 TYPE OF FINANCIAL SECURITY: DASH/CHECK ANNUAL APPROV• -IGNATURE: TITLE: r DATE: 1 !'- t4 111/0 _ Pu 6c, LAJaK-5 • G FROM ......., <THU>...1Uti 25 2009 \/5T. 7:18/No.7500000828 P 1 • slml BSW SKETCH FORM • MM0901641 Fax•fd=877:'4.19 2634"/303.091 2114 Nectas#: •NPA/ NNX (Wire Center): • / 't 65)_ (3c Date Submitted: b. �f'1 Installatio /Repair/ reprovisioning Customer Name: . (Please Circle a Above) I - �Q� ��� Job ID 033.356Q033.356Q Address: 4//6 IPork, 4vt City: TN 911 Address: J 1.Held For BSW 0 Phone: CBR: 6S - 511` 7c1 . . . 2.Held-cannot locate ENCAP Subdivision: Lot: Block: 3.ops-Can not lay temp 0 County Wth6.1'1 Section Range Township QuarterSectlon(Circle one)NW - NE - SW - SE 4.Held for F1-F2,also need BSW 0 Submitted By 5.Temp Placed-(Need Sketch Below) ,0 Name: Lof1hSC':f EC: 5j Pgr/Cell: 6a erg"&397 • 6.Found Temp -Same Job ,J Supervisor: Chris Kdrbisch -Other Location El Office#: 651 777 5062 Pager: 612 622 0228 7.Add Line -Customer was contacted: • verbal card — • Hudson/King: Yr. O5 Pg. /837a Terminal Address: •F 15 Ic O 6s-vv,S-r Cross Street: 5-t-1' 5-r Total BSW Footage: 300 Type of Wire: 3pr (3pr I 6pr) L-INFO; L- 5 5 3. A_ 3 5 G LE F,R.S N,E,S,W 1-2-3-4-5-6-7 W.S,P,O.0 G,A,M.N 3/6 S,N P,N C • Indicate North • as • ��� � - • . ' . • ' • a PA 8 1• • (1\01 E Length of BSW in ROWri5 Dist of BSW from Curb Q . . Dist from term to CIL A� tr j,/o h -r-6:-N,f/ foK.A (.-V+v Dist from term to Cross St n5. !r f7 I /�A _ Dist of Ci L to Curb 15 "` \\\ 1/,/I4 C Dist from Curb to Sidewalk +' . Width of Driveway iq Width of Sidewalk - • STATE HWY Mile Marker# r. Road Push ...kft Permit Required A Hand Dig [] (Note:Hand Dig,Must be 12°) (Confidential:Disclose&Distribute solely to those having a need to know.) Revised:01/08 06/25/2009 6 : 15AM ACORDTI, CERTIFICATE OF LIABILITY INSURANCE 9/152009 DA81142009 PROS Lockton Companies,LLC-1 Kansas City THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 444 W.47th Street,Suite 900 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE cHOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Kansasity MO 64112-1906 s C0ty-9ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. (800 INSURERS AFFORDING COVERAGE NAIC# INSURED MASTEC NORTH AMERICA,INC INSURER A: ACE AMERICAN INSURANCE COMPANY 1059808 17385 FOREST BLVD N, INSURER B:NATL UNION FIRE OF PA PO BOX 519 INSURER C: INDEMNITY INS.CO.OF N.AMERICA HUGO,MN 55038 INSURER Ir TRAVELERS PROPERTY CASUALTY I INSURER E: COVERAGES MASTEC01 SE INS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CON1RAGT BETWEEN 7HE ISSUING INSURERS),AUTHOROSO REPIESENTATNE OR PRODUCER AND TIE CERTIFICATE HOLDER THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSPI LTR ADM NSWTYPE OF INSURANCE POLICY NUMBER fDATE MID YI P MY{ME MID VYY71)) UNITS GENERAL UABJUTY EACH OCCURRENCE $ 2,000,000 ENTED A X COMMERCIAL GENERAL LIABILITY HDOG23744697 9/I512008 9/15/2009 PRS TO ) $ 500,000 ICLAIMS MADE 0 OCCUR MED EXP(My one person) S 25,000 X XCU&PROD/COMPLETED PERSONAL&ADN INJURY_ $ 2,000,000 X CONTRACTUAL INCLUDED GENERAL AGGREGATE $ 15,000,000 GENL AGGREGATE UNIT APPUES PER: PRODUCTS-COMP/OP AGG $ 6,000,000 1 [] nLOC - AUTOMOBILE UABIUTY COMBINED A X ANY AUTO ISA1I0824781A 9/15/2008 9/15/2009 accident)s11�LEUMIT $ 3,000,000 ALL OWNED AUTOS BODILY INJURY _ XXXXXXX SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY a INJURY $ XXXXXXX X NON-OWNED Amos X POLLUTION LIABILITY — AMAGE (Per TM) $ 30C7QO{XX GARAGE UABIUTY AUTO ONLY-EA ACCIDENT $ XX7O{XXX R ANY AUTO NOT APPLICABLE OTHER THAN EA ACC $ XXXX)OOC AUTO ONLY: AGG S XXXXXXX EXCESS/UMBRELLA UABIUTY EACH OCCURRENCE $ 2,000,000 B E OCCUR I (CLAIMS MADE BE 7251634 9/152008 9/15/2009 AGGREGATE $ 2,000,000 UMBRELLA $ 30000001 DEDUCTIBLE X FARM $ XXXXXXX RETENTION $ S 30000001 A WORKERS COMPENSATION AND WLRC42850986(CA/AZ) 9/15/2008 9/15/2009 X ITORY UN ITS I I A EMPLOYERS' SCFC42851024(WI) 9/152008 9/152009 E.L EACH ACCIDENT $ 1,000,000 ANY PROPRO PRIETORIPARTNER/EXECUTIVE C OFFICER ER EXCI.IMEDTNO WLRC42850949(AOS) 9/15/2008 9/15/2009 EL DISEASE-EA EMPLOYEE S 1,000,000 lives,deaaffie and r SPECIAL PROVISIONS below E.L.DISEASE-POLICY UNIT S 1,000,000 D OTHER KT1CM13296T366108 12/31/2008 9/15/2009 $10,000,000 ANY ONE RENTED/LEASED OCCURRENCE SUBJECT TO EQUIPMENT 51,000,000 MAXIMUM PER ITEM. DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION 10627884 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CITY OF OAK PARK HEIGHTS DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN 14168 OAK PARK BLVD. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL OAK PARK HEIGHTS MN 55082 IMPOSE NO OBLIGATION OR UABIUTY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHO NN RESENTATIVE ACORD 25(2001/08) For qu.stlone maording Me aerateete,content U,.number Noted In A.'Producer'sectIon above and specify the a• MVP. 0 ACORD CORPORATION 1988