HomeMy WebLinkAbout2010-05-14 ROW Permitt ,_, , �. � .
�� P RM N . : DATE
APPLICANT :: ORMAT I
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L1IJt}.J T P � F PRIVATE U T I: ,IA T hF
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L COMERMAL r/RIVWAY
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CONNXCT1ON TO CITY ' `.'E t QUIRES PREPAYMENT O +' 1 cc :$8 FEES):
r IASTORM SE WE
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Must have full marking of new tti 1 i f. 1.e ')
EXPLANATION 0 r O2 ADDITIONAL T ::(:)NAL } '4 {l
City of Oak Park Heights
RIGHT—OF—WAY PERMIT FORM
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NTMCT RINFORMATION:
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APRON (WIDTf.r2)
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and restoration.
$x.50.00
CONTRACTOP PERFORMING WORK MUST T ATTAC CURRENT CE TI CAT ; OF I 'S . NAMING THE CITY AS
AN .iD ,s. `�` �. �*�. �! '�' ' S 4.�� � �J � ~'€�.'� .� AMOUNT ...,...,..,.. 9 ?},�{'�c� .. ¢ , Y {-+ #+�+ /� �'} f� � 4 y y � �[' . ,,. � q t' � 4 ...,., � y � ,— "....,.,.,.,..._,...,. / � ..
rxw�. 4..,—..,... .....Tr..,.,,..,.- ,.,�,.. -r- ~ w,.� .. .. AN NO!. LESS THAN $1 .,,,. fOOO , O 3.J LY.t.. HOUJ4 SUC!3 P i 0
' wu € CE PERMIT i . . ' ISSUED
J ,��� , T _PROOF �
WHAT THE WORK ILL INVOLVE (REQUIRES S kC U}x-4T J. TO PROTECT :J ,N 1�F lSf.'RUC`$' OR{/ / M1.OMP LE
RESTORATION. k ompi. {:'x . Irin8 m a y incur additional costs ..:C }7. mitigation plan rt v?.C='; and
1 n s > _' c t..i o n ; . Mil_ : '. include C:.. - L? d e : 3 ,. :i, o `- protective r. r r 3 sir - -. 6 - ;
` �� � C- � i7 control, r� L- �': C� -1 f ]t; E -. �� ..x x,� , {.. f and �� 7 :� �_, - �,. C? ; -� r;c r ,L. o n
611 n e w -t- , L:- i ' -- . m u f. be full.y }} ..a o for , : }}. . o/ r 3 x 8 ,
P 7 4.Y.1WET OPEN CUT (require approved plan with ak.r {.}i{.~/•i f
full width 3; ;=sUc,;a ;io 1 s j ty 7:f;.'.0 i1-3-1: '-( }
rAPATHAY C O {' {f ' } ti - • with } } width }- x i~ 1 ,-; t .. +- iti -Y l
- i � }- 3' {- _ C.t plan -�- C.i : 1 L'� �. ���:. !� � i 2 . - l•, :L. {: � �, � � ?: C? ,� i -. ( :� ?: x, .]. (:� i? and {,� . { C,� i] 1: -.. �; 1 � ±; o r +;
[.JEXUAVAT:WNIN BOULEVARD of CITY 0. P R O P E R T Y (requirc,s Y plan and 2e(:urity f:or
:ei3t.or i sion}
O R. 4! . T2! . ACCESS ( 1: e c u - }- C'} s approved .. a n on u€ -5 c r S S y
PRO START T [)! ` Y'i
PRO PO S DATE:
Name
Applicant agrees t . ide by and follow all applicable
ordinances, laws, rules, and regulations ; : all u Cory
bodies, including but not limited to cit y, county, state or
federal regulatory agenciesc Applicant acknowledges that
placement s utilities in any Right-of-way is subject to the
rights n rules : the City Of Oak Park Heights, Damage, loss or
destruction of applicant's f ,ail. ie and/or its resulting
business interruption f l not be restored, compensated or
reimbursed by the City in the event the City needs remove,
relocate or terminate such facilities while accssing its utility
services in the rea for .y reason, r.. ;. utility locates are
required by the owner and/or applicant for the utility in the
Right-of-way . in rp {t .; .ty .
The ppl c hall provide, at its sole xp s , full "as-built"
drawings gs for all infrastructure re i t led in h City Right-of-
way. All "as-built" d wi shall he completed by a licensed
Minnesota Engineer or Surveyor, "As--- iit " shall be provided
paper and digital frm acceptable to the City of Oak Park Heights
including GPS coordinates in the Washington oun oordin to
system, The City additionally reserves the right to remove
and/or deactivate any and all installed infrastructure a, d in
its Right-of-way should these " -built " not be provided
should these prove inaccurate.
The Applicant accepts perpetuity the e po ibii ty to perform
at its expense all necessary locates (Gopher State One Calls)
that ay arise or be requested in the future by the City or other
parties, The Applicant does release and hold harmless the City
from ny and all responsibility for utility / service locates.
APPLICANT SIGNATURE - by your signature you accept and agree to
all conditions as . above. Must he signed by owner,
preside r CEO of firm installing utilities_
T tie
Signatur
Date:
k o 0
Phone #: (c-)- * SS -
PERMIT EXPIRATION DATE :
ILLA
SECURITY 'ESCROW AMOUNT REQUIRED: $
HAS PROOF IOF INSURANCE BEEN SUPPLIED?
L
TYPE OF FINANCI SECURITY:
FT CASH/CIIECK
D AUAL
TITLE:
(
DATE:
AY FEES
CHARGES
Be Permft Fee $1SO+
Includes initial review, plan and restoration review, permit issuance and tracking, one final
inspection.
Additional Hourly Fee $8O per hour
Based on regular hour rate, does not include. overtime or minimum hours for non-standard work
hours,
Engineer /Lego Services Actual Cost +1Q%
Developer is required to pay for ail City-out of pocket expenses; e.g. contract work as required by
the City for review, testing, additional mapping, digitizing, survey work, recording, etc,
Re-inspections CA hr min) $60 per hour.
Escrow Deposit Requirements:
Tracer wire installations in grass ROW shall have a $1.000 dapoait, minimum, in case engineer
needs to be brought in to survey and peform a trace. Separate escrow amounts will he required
for street or trail impacts or other excavations based on proposed project, materials and areas to
be disrupted. Fees for trenching, excavation, and additional infrastructure impacts will he
estimated prior to permit issue and be adjusted for additional work on an hourly basis,
PRODUCER The Insurance Agency
11 200 Stillwater Boulevard North
Lake Elmo, MN 55042
Phone (651) 366 -6886
INSURED Fuhr Trenching
12639 Manning Tr
Hugo, MN 55038-
COVERAGES
3 + THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD 1NDICATE0. 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 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIIVIITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM,
..._......, .... ..... .................. ............. .................... ................................ ........... ......._................ ................,
INSft ADD', 1 POLICY LIMITS
....... �FED�IE ' pOL� EXPIRATION EXPIRATION I`��� �
�
LTA ; Ift
TYPE OF iN15 RANDE POLICY I UMBE � t kl lDDI Y DATE (IV I [3D/ Y
. EACH OCCURRENCE
DAMAGE TO RENTED
04/07/10 04/07/11 P E 1I E (Ea o r ......... ....
MED EXP (Any one person)
PERSONAL & ADV INJURY
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGG
............ .
COMBINED SINGLE LIMIT
04/07/10 04/07111 (Ea accident)
BODILY INJURY
A (Per person)
BODILY INJURY
(Per accident)
A
GENERAL LIABILITY
Iv] COMMIERCIAL GENERAL LIABILITY ' L80890
i . ' CLAIMS MADE OCCUR
}
G AGGREGATE LIMIT APPLIES PER:
POLICY �.... PROJECT _..... LOC
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON OWNED AUTOS
GARAGE LIABILITY
ANY AUTO
E(CESSIUMBRELLA LIABILITY
CERTIFICATE OF LIABILITY INSURANCE DATE (mm/oorvv) osnono
OCCUR CLAIMS !MADE
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETOR / PARTNER ! EXECUTIVE
OFFICER ! MEMBER EXCLUDED?
If yes, describe under
DEDUCTIBLE
RETENTION
CERTIFICATE HOLDER
ACORD 0 110) QF
City of Oak Park Heights
14168 Oak Park Blvd
PO Box 2007
Oak Park Heights , MN 55082
Fax (651) 704 -0286
L090
L80890
'L80890
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
} HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW.
..................
}
Ii SUF EI S AFFORDING COVERAGE IAI # }
Li A.; A u
INSURE B;
1
INSURER i
■ INSURER D:
} INSURER E:
INSURER F:
04/07/10 04/07/11
04/07/10
SPECIAL PROVISIONS below .
OTHER
,
DESCRIPTION OF OPERATIONS /LOCATIONS 1 VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PR
Septic / excavation
AUTHORIZED REPRESENTATIVE
PROPERTY DAMAGE;
(Per accident)
AUTO ONLY - EA ACCIDENT
1,000 000
100 000
000
1,000,
2,000,000
2,000,000:
1,000,000
1,000,000
1,000,000
1,000,000
OTHER THAN EA ACS ....: ...... ...............................
AUTO ONLY; }
EACH OCCURRENCE 2,000,000
AGGREGATE 2,000,000
04/07/1 ! TORY LIMITS ,.. :.. Ri . .
E.L. EACH ACCIDENT 500,000
• ,
} E,L. DISEASE - EA EMPLOYEE1 500,000
El, DISEASE - POLICY LIMIT 500,000
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO
THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
ACORD CORPORATION 1988
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