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HomeMy WebLinkAbout200014 OPH Right of Way Permit City of Oak Park Heights RIGHT-OF-WAY PERMIT FORM CITY PERMIT NO. : 20 - PERMIT FEE: ai.Pimua $150.00 COMPANY PERMIT NO. : DATE: APPLICANT INFORMATION: DEVELOPMENT/ ADDITION / LOCATION DESCRIPTION OR. SITE ADDRESS: a'Z STA( fa,A[At era, ✓tei OWNER (Applicant) : #©sVr1(&)_'r4012_kL Sefek.,ILES UTILITY COMPANY: /-1 L f Eart, CONTACT PERSON: STEVE �T-C N28 TELEPHONE NO: !-K3%-lie 37 ADDRESS: 30C f IAKQ6-t Ci 7-)2./ e; CITY: C, 7 LSTATE:r1A/ZIP CODE: .253 CONTRACTOR INFORMATION: CONTRACTOR PERFORMING WORK: I I1 L LP2 P-144.4"0.44-71.44,0 I d✓L, / CONTRACT NAME: CONTRACT NUMBER: PHONE: 4g/-/37-14,37 CONTRACTOR PERFCMGCMG1AFRK MUST ATTACH CURRENT ('ERTIFCATE 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 RILL HE ISSUED. TYPE OF WORK : TY L_NEW PRIVATE UTILITY iiIEPLACE/REPAIR 5t R- 1-44re" LJCOMMERCIAL DRIVEWAY APRON (WIDTH?) feet RESIDENTIAL DRIVEWAY APRON (WIDTH?) feet CONNECTION TO CITY SYSTEM (REQUIRES( PREPAYMENT OF ACCESS FEES):• LJWATERMAIN I UILSTORM SEWER IC4ISANITARY SEWER R. PhllZ EloTHER 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) (EXCAVAT.ON IN BOULEVARD or CITY OWNED PROPERTY (requires approved plan and security for restoration) L 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: R L r Sn� S�� LI Air (....31 '' P✓C. 19 PROPOSED START DATE: 6// !1 7,9 PROPOSED END DATE: p/ z-I 0 7 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 t'ii1 c T tL4 w F P Title vd,)o SignatureY c (2.-,a-en= Date: 1f(t//Oy Phone #: -OD 37 20 ^` PERMIT EXPIRATION DATE: 49 / I 6 9 SECURITY ESCROW AMOUNT REQUIRED: $ ` HAS PROOF IOF INSURANCE BEEN SUPPLIED? ,),/4 S nn 1 TYPE OF FINANC = SECURITY: UCASH/CHECK LIANNUAL APPROVAL H TUBE: TITLE: DATE: .,,,,,__,/ ,f.„/". Pv ktitkG ULic4CS q - 1 -1 21 'ro J hlNA i IQ t . 1 I L1 � RtT 1 v l vif i i i 4/c),,...- •..... iii I v„n f i iti i c l ti 3 14� % 9,-- V iNs- Li w) 1-(1-"dE (5 LH 4o/ I A VI1 C t v 4)