HomeMy WebLinkAbout2009-08-20 Right of Way Permit Application 08/17/2009 08:18 651 - 770 -6063 QWEST -KEN BRANDT PAGE 02/05
City of Oak Park Heights
RIGHT -OF -WAY PERMIT APPLICATION
CITY PERMIT NO.: 2009- PERMIT FEE: minimum $150.00
CONST. PERMIT NO.: DATE:
APPLICANT INFORMATION:
DEVELOPMENT / ADDITION / LOCATION DESCRIPTION OR SITE ADDRESS: Qwest Job # RWM9M1091
F14420 Upper 56 R. No.. Oak Park Heights (xst Omaha Ave. No.)
•
OWNER (Applicant): Ken Brandt
UTILITY COMPANY; Qwest CONTACT PERSON: Ken Brandt
TELEPHONE NO: 651-777 -1525 ADDRESS: 1890 Gervais Ct.
CITY: Maplewood STATE: Minnesota ZIP CODE: 55109
CONTRACTOR INFORMATION:
CONTRACTOR PERFORMING WORK: STF Services, Inc.
CONTACT NAME: Paul Holman LICENSE NO.: PHONE: 651-248 -6480
• CONTRACTOR PERFORMING WORK MUST BE LICENSED BY CITY & PROVIDE REQUIRED
INSURANCE CERTIFICATE
• HOMEOWNER MUST PROVIDE CERTIFCATE OF INSURANCE NAMING THE CITY AS AN
ADDITIONALLY INSURED, IN AN AMOU'N'T NOT LESS THAN S1000,000.
WITHOUT SUCH PROOF OF INSURANCE NO PERMIT WILL BE ISSUED.
TYPE OF WORK:
❑NF.W PRIVATE UTILITY ❑COMMERCIAL DRIVEWAY - APRON (WIDTH) Ft.
X REPLACE/REPAIR ❑RFSII)EN11AL DRIVEWAY - APRON (WIDTH) Ft.
CONNECTION 10 CITY SYSTEM (IWOUIRES PREPAYMENT OF CESSFE.5 :
❑WAJ'IiRMATN ❑ STORM SEWER ❑ SANITARY SEWER ❑OTHER
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 based on the attached requirements
for water, sewer and other utilities).
❑ STREET OPEN CUT (requires approved plan with access, traffic control, and inspected full width restoration - security requited)
❑ PATHWAY CUT (requires approved plan with full width restoration and security for restoration)
X 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)
�
EXPLANA •• .
rew will be digging up a wet buried splice in the boulevard between 14420 & 14412 Upper
St. No so tech can repair & restore service. Contractor will restore area when tech has
the splicing
PROPOSED START DATE: 08/20/09 __, ^._ PROPOSED END DA'L'E: 08/27/09
08/17/2009 08:18 651 - 770 -6063 QWEST -KEN BRANDT PAGE 03/05
Applicant agrees to abide by and follow all applicable ordinances, laws, rules, and
regulations of any other 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 of the City Of Oak Park Heights.
Damage, loss or destruction of applicant's facilities will not be restored,
compensated or reimbursed by the City and in the event the City needs to remove or
damage them in accessing its utility services in the area for any reason. Private
utility locates are required by the owner and/or applicant for the utility 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.
K...__,Oec_. .1,..____S;i .531649'
TITLE: Contract Work Inspector DATE: 08/1.7/09
TO BE COMPLETED BY CITY:
LICENSE & /OR CERTIFICATE OF INSURANCE PROVIDED? ' / NO
PERMIT EXPIRATION DATE: REQUIRED SECURITY:
' 7 -z4 — o9
TYPE OF 4 . ANCL4L SEC a " ❑CASH / CHECK
APP' ,7 " IGNATURE• TITLE: DATE:
/. Oi a P.- (4 I fol
FEE ALCUL ION: ROUTING:
Right Fee: _ Original to Finance
Copies to: Public Works
Security Fee: _ Property File
Applicant
Total Due:
Printed by mncdrom at 03:35:26 on 10/Aug/2009 for WC CLLI: STWRMNST Data current as of 07/Aug/2009 R WM 9 M i d9 f 44K MAK 14 TS.
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Z [ME4]
251 ft (45C) (1976) `
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i'+420 5990 -0, 601 -700 cn
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R56650 5990 -0, 651 -67 480 ft (45C) (1976)
[T ) SPA ALMW 25 m
UN, 1- l 5990 -0, 601 -625 ' m
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14412
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I m 145 ft (45C) (1976)
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OSP Viewer CONFIDENTIAL Disclose and Distribute Solely To US WEST Employees Having a Need to Know. Sheet 1
08/17/2009 08:18 651 - 770 -6063 QWEST -KEN BRANDT PAGE 05/05
- MASTEC -
Date Called to Close? Job Completed?
I'JOB # RWM9M 1091 I
. M76480 Oak Park Hts. 14420 Upper 56th St. No. (xst Omaha Ave.)
AREA LOC CITY ADDRESS
1 X ROUTINE 1 EMERGENCY HUDSON # 371 -5C
08/20/09 08127/09
START DATE COMPLETION DATE
ITEM # QUANTITY CODE JOB DESCRIPTION
6503A 1 45M B Crew (find splice)
2535A 1 45M Open Pit
2536A 1 45M Close Pit
6501A 2 45M A Crew (restoral)
5310A 200 45M Sod Placement
Cable Count: 5990 -0, 651 -675
Stillwater Wire Center
- DESCRIPTION OF WORK -
Andy Case would like a wet 25 pr. encapsulated splice dug up in the front of the
above address. Andy said it is in a cul -da -sac between 14420 & 14412 Upper 56th
St. No. He has the spot marked with a white painted box & flags. Call for 48 hr.
locates and have them mark a 50' radius of the marked area. He is hoping the splice
is right next to the driveway, but it may be under the driveway. We will have to see!
When tech is finished with the splicing, crew can restore the area with black dirt &
sod. Andy will be piecing out cables and placing a new 6" pedestal on the property
line. Andy did talk to the customer.
Ken Brandt 08/17109 X PERMIT I will apply for
(CWI) (DATE) yes no (PERMIT #)
TECH: Andy Case CREW: Cable Maintenance
PAGER: 612 -267 -1835 Eric Whisler
(SUPERVISOR)
CELL: 612 - 267 -1835
_ S T F Services, Inc.
CONTRACTOR
d CERTIFICATh OF LIABILITY INSURANCE �„
PRODUCER THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION
Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
1301 5th Avenue, Suite 1900 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Seattle, WA 98101 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Attn: Kathy Hariri 206 - 214 -3119 Fax: 206-214-3483
100429- QC-GAW -08-09 kbh cost none INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURER A: National Union Fire Ins Co Pittsburgh PA 19445
QWEST CORPORATION
1801 CALIFORNIA STREET, SUITE 1150 INSURER e: Insurance Company Of The State Of PA 19429
DENVER, CO 80202 INSURER C:
INSURER D:
INSURER E:
COVERAGES 1
THE POUCIES 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
CONDTIONS OF SUCH POUCIES. AGGREGATE UMRS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR POLICY EFFECTIVE POLICY EXPIRATION
LTR I TYPE OF RISURANCE POLICY NUMBER LIMITS
DATE pavuonrrrn DATE DENNIDITTYY)
A x GENERAL LIABILITY GL1871962 10/01/2008 10/01/2009 EACH OCCURRENCE $ 1.000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 1 000 000
PREMISES(Ea occu ence) $
CLAIMS MADE 1 X I OCCUR MED EXP Iva me Person) $ 10,000
PERSONAL S ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GENERAL AGGREGATE UMMR APPLIES PER PRODUCTS - COMP/OP AGC $ 2,000 000
PRO-
POLICY n JECT n LOC
AUTOMOBILEUABJUTY
A CA6077462 (AOS) 10/01/2008 10/01/2009 cousaiEDSINGLELimn
A X ANY AUTO CA6077463 (CT) 10/01 /2008 10/01 /2009 (Ea accident) 2,000,000
A X ALL OWNED AUTOS CA6077464 (MA) 10/01/2008 10/01/2009 BOaLY INJURY $
A SCHEDULED AUTOS CA6077465 (VA) 10/01 /2008 10/01/2009 (Per Pemml)
X HIRED AUTOS BODILY INJURY $
X NON-OWNED AUTOS (Per accident)
X SELF - INSURED FOR PROPERTY DAMAGE
(Per acddent)
AUTO PHYSICAL DAMAGE
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $
IN OCCUR CLAIMS MADE AGGREGATE $
$
DEDUCTIBLE
_$
RETENTION S I $
B COMPENSATION AND WC4800675 (AOS) 10/01/2008 10/01/2009 X I S TIYI TU T.C1 IO R
B EMPLOYERS' LIABILITY WC4800676 (CA) 10/01 /2008 10101 /2009
ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WC4800677 (FL) 10/01 /2008 10/01 /2009 -L EACH ACCIDENT $ 1,000,000
B ( PE OIRCE o RI ry M in EM 1 B � ER y EXCLUDED?
A N Wt;4800678(OR) 10/01/2008 10/01/2009 LL DISEASE- EA EMPLOYEE $ 1,000,000
S M a atV SIGNS CIAL VI b elow under .L DISEASE - POLICY LIMIT $ 1,000,000
OTHER
B Workers' Compensation/EL WC4800679 (TX) 10/01/2008 10/01/2009 Each AcdEmp/Policy Limit $1,000,000
A Workers' Compensation/EL WC4800680 (ND, OH, M, WY) 10/01/2008 10 /01 /2009 Each AccJEmp/Policy Limit 51,000,000
A XS Workers' Compensation/EL XWG4801276 (WA) 10/01/2008 10/01/2009 Excess of 51,000,000 SIR $1,000,000
DESCRIPTION OF OPERATIONS/LOCAllONSNEIKCLESDCCLUSIONS ADDED BY ENDORSEMEH1 SPECIAL PROVISIONS
RE: FOR ANY AND ALL WORK PERFORMED BY QWEST CORPORATION RELATED TO PLACEMENT AND/OR MAINTENANCE OF
TELECOMMUNICATIONS FACILRIES. CERTIFICATE HOLDER IS AN ADDITIONAL INSURED PER THE GENERAL LIABILITY BLANKET ADDITIONAL
INSURED ENDORSEMENT AS RESPECTS THEIR INTEREST IN THE OPERATIONS OF THE NAMED INSURED AS REQUIRED BY WRITTEN
CONTRACT.
CERTIFICATE HOLDER SEA-001459224-01 CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE
CITY OF OAK PARK HEIGHTS EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
ATTN: ANDY KEGLEY 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
14168 OAK PARK BLVD NORTH
P.O. BOX 2007 BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND
OAK PARK HEIGHTS, MN 55082 UPON THE INSURER, IT AGENT�S OR REPRESENTATIVES.
,1NI�.Da @R�BfrATNE /'i Jai / 6 �'^�
Cheryl L Koch
`r.. —'7�`�
ACORD 25 (2009/01) 01998 -2009 ACORD CORPORATION. All Rights Reserved
The ACORD name and logo are registered marks of ACORD
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
This Certificate of Insurance 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 (2009/01)
•
•
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Q RO 310084 LOCATION )41 "•-- 1°
Atri DATE 1
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ENDORSEMENT OF THIS CHECK BY THE PAYEE
ACKNOWLEDGES FULL PAYMENT OF THE FOLLOWING: 4
nk of America 238350
(PLEASE CASH OR DEPOSIT PROMPTLY) Sok el Aim* 04steener Oeenomilen
Communications, Inc. Book el Am** 14.A.
1244alb 84 044,414 64
611
YOUR STATEMENT OR BILL Nd Atzbi: # / tlATED 41 4.240/ NOT GOOD FOR MORE THAN $500.00
&4) DOLLARS $
PAY
TO THE td.- . • Owest Communications, Inc.
ORDER t!!
OF / •
\4 0:1,474,. ",e SI ATURE
4 4, 4 4(44L fre e:60.1,A VOID MONTH R ISSUE
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