Loading...
HomeMy WebLinkAbout2009-08-21 Comcast 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: g o w I - SER0 2 0 fro, "=a OWNER (Applicant) : C 0)'l. Ccc UTILITY COMPANY: C o/K C a Sf CONTACT PERSON: k'-e L& �UN O(... I TELEPHONE NO: -?SS-J 9a7 ADDRESS: t 70s Dc to Po. K CITY: � 'IA 1 Y k STATE:M tIZIP CODE: 37,„5-3 Y CONTRACTOR INFORMATION: CONTRACTOR PERFORMING WORK: U (/\i V Q V' S o.( > e r u l'--e CONTRACT NAME: TrotU S CONTRACT NUMBER: 7G 3—)3gPHON7:1 73 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 LNEW PRIVATE UTILITY LJ lLIREPLACE/REPAIR LLICOMMERCIAL DRIVEWAY APRON (WIDTH?) feet (RESIDENTIAL DRIVEWAY APRON (WIDTH?) feet CONNECTION TO CITY SYSTEM (REQUIRES PREPAYMENT OF ACCESS FEES): nELATERMAIN ❑STORM SEWER ❑SANITARY SEWER LJOTHER 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): al I (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) 3, XCAVATION IN BOULEVARD or CITY OWNED PROPERTY (requires approved plan and security for restoration) 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 21 2009 I) I rc c + t O vt Boli -Pr c ii E X i S-H hp Pro() col kA, 23--0 ' 1-o ' In t 5oo-1-1l PROPOSED START DATE: (ju Ill e &i Perm i/l eel PROPOSED END DATE: LV b.Y� 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 et. .et Title rOMI-A-e ff C(Ca ( CCG Ira 1 Viccf or Signature ' Date: g- t? -.2o C7 Phone #: G 3-1 ——7.S.57:- 1 9 a -7 TO BE COMPLETED BY CITY PERMIT EXPIRATION DATE: Q l taVoti SECURITY ESCROW AMOUNT REQUIRED: $ HAS PROOF IOF INSURANCE BEEN SUPPLIED? �e.C TYPE OF FINANCIAL SECURITY: LASH/CHECK L___IANNUAL APPROVAL SIGNAT • : TITLE:IDATE: i.,% /. ._______ p .A. -l• ard4 o9 /01G 1 } 0 c 1 Ln l 5„.„..-4\D J - o ,LLS 02d ,821 0 ,OS2 0 a SA Oo � 9 ® 2 CU a \ S. F— \ F— co E m z� Lo CO a rn o m \ M M n N \ Co7M � 3 `V O co v N O J Q W�oi I —Op P aNN 0 CO L_CO E i _ W �Mv aU c0 Z .4-N N N Z LLJ EL / 1 A M ^03 ACU ((' —.I W N I Ln 3 'llco °N =.< _ • - a_ oo409 CO COI-09 _ Q. co ' . I—I0 N n • 11• tri in0 �- NN ,VJ Q Q � rn a I M NN O d DO Et O t..i7 v 1--) . O wriAia aU to N 5 4 op n N -�' 2 Q N N N o < Ly -) O o U) N 3/\d 3N3-10 VD CU o CO VD C CU w D M oo 03 Oa in in inCO co In CN n m CO Li)\N LID. 0 CT U) J S ,6 0 0 J o ,LLS o \X -a- -I-1 0221 ,82I o OSz 0 a aSA 0 © �t • • ® 2i N / IP1- 1-H co EJ D m z as COco tn M M O O a ^N \ CO o '-)co� N^ 0 r _._J • W r\ ai 1 — CO + 3 D_N N LL O it LA V O L Co Q W M < U nq N < N 210 - ^ L N N NLE cci ^ w /1 i7 a M lip I— W N .. "'OD 3 GN . . 00h _1 c) Uoo , ( i . a- oo � m �� Q � o 0 —OD M M Lc, of F-I N ''')co— rn_16 i0,. a .1. ,,,-s>u7 M 1-D < rn< 1 O c� a N N /iw])l�/ Et W M U (O cn Coo0 W D i .tc7� N Q N N N 0 0 < W 7 \D .-) 0 (i) N ❑nd ]Nr1❑ - `p CLI o CO q) Cu CO co co cc Cb Cb c co o co Un Ln CX) coco co N coin ryn Qn m 1 n in N Ln. • 0 On 1 Lf-) l S 16 a 0 1 J o ,LLS -I X -1-1 0221 8a1 o OSZ CD o — a SAC" - o >63—• ® ai CN: " , N p \ H— \ � CO CI Cb U inU) OMao v NN 0 ) v® —1 a N N �}t M C O }Ln v o i- W WDM g20 L.7 - u� o(�� 12 Q N N N O X —I OP o p o 0o cu 1--- III CI. N� �D Q il • a. o ' —m co 3 ._.J W N Cr' 'D a o 1-- H J N CD Q M M N tn di NN (A<I O a�CV I M00 W N N Cot Ct O } a O in /��.�/ W , 4' Ti- U S' W 1( N < 1� N - �1 [�,\j Q N N N k . V :2i `!/vim[/ �W �/ <'�1 ' (--- \Q .�in ti 0 0 o N 3AV 3N330 .D CU o CO VD CU CO d" co .-, CC CO COO O O CO up (o in co co co Cb Ir) Ln ACORD„ CERTIFICAT )F LIABILITY INSURANC OP ID SG DATE 11111000/YYTY) PRODUCER UNIVE8/8/188/09 THIS CERTIFICATE IS ISSUED ASA MATTER OF NOORMATION - s ONLY AND CONFERS NO RIGHTS UPON TIE CERTIFICATE Faribo Ins-Hastings Branch S S. Frontage- g HOLDER.THIS CERTIFICATE DOES NOT AMEND.EXTEND OR 1303 Suite 4 ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW. Hastings NN 55033 Phone:651-319-0613 Fax:651-319-0624 DEURERSAFFORDING COVERAGE NAIC• BISTmED INSURER A: West Bend Mutual 15350 Universal ISURER B: =tie Ces 2440 INSURER D: �akda�e MN 55128 o- EVER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE$ISUREO NAMED ABOVE FOR THE POLICY PCHOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TEAM OR COMMON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES RETS)HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONOmONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLASNS. p ��y ER HI LMRE DApTE[IIM1D0CTIVErm IAT LW$ LTR TYPE OF ISURAIN POLICY NUMBER GMERAL LMBIUTY EACH OCCURRENCE $1000000 A X 03111EMNALGommtummury BCN1075023 02/19/09 02/19/10 P ".Dj �,..,�, :100000 Cu'sMADE Film= NED EXP(My ernspunon) $5000 X $100 PD DEDUCT PERSONAL.&ADE INJURY $1000000 GENERAL AGGREGATE $2000000 _ GENLAGGREGATE LIMIT APPLIES PEN PRODUCT$-COIpJOPAQG $2000000 -1 POLICY n JECT n LOC AUTOMOBILE LAMM COMBINED LEST $1000000 X x ANY AUTO BCN1075023 02/19/09 02/19/10 (E••ccid■w ALL OWNED AUTOS — Y M SCHEDULED AUTOS (VP ) Y HIRED AUTOS HOOEY NON-OWNED AUTOS (Pr oINJURY ccident) _ PROPERTY DAMAGE GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY! AGG s EXCESS/UMBRELLA LEABIUTY EACH OCCURRENCE _ $5000000 A ii OCCUR CLAMSMADE CUN1075025 02/19/09 02/19/10 AGGREGATE $5000000 s T_ DEDUCTEILE s x RETENTION $WAIVED $ — WORKERS COMPENSATION AND Z TOWC RttLILM - 10E01- AANY PROPRIETOR/PARTMERIEXECUHVE WCN1075024 02/19/09 02/19/10 ELEAaHAOCIENT $500000 OyFFIERIP.E&IS R EXCLUDED? EL DISEASE-EA EMPLOYEE $500000 SPECIALPROV>SIO[ISbdow EL.DISEASE-POLICYLLVIT $500000 -OTIIER DE$CRRTIOH OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT)SPACIAL 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 sHOIILD ANY OF THE ABOVE POLICES BE CANCELLED BEFORE TIM EXPIATION DATE THEREOF.THE ISSUING INSURER mu.ENDEAVOR TO MAL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL City of Oak Park Heights ■POSE NO OBLIGATION OR LIABILITY OF ANY RED UPON THE INSURER.ITS AGENTS OR 14168 Oak Park Blvd NO Oak Park Heights MN 55082 REPRESENTATIVES. MRHOR® tTA Susan G Moll ACORD 25(2001/08) ©ACORD CORPORATION 1983 • • IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the poli y(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)