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HC 5136(9�98� PERMIT FEES HENNEPIN COUNTY Permit No. i a�� O 7 Transportation Department MUNICIPALITY - S50.00 Operations Division - Permit Office Counry �� ALL OTHERS = S75.00 1600 Prairie Drive-Medina, Minnesota 55340-5421 Road Nu. Phone: (612)745-7600 FAX: (612)478-4002 MUNICIPALITY PERMIT APPLICATION FOR UTlLITY CONSTRUCTION C� �G�� LOCATION AND/OR DESCRIPTION OF WORK:Application is hereby made for permission to place,construct and thereafter maintain a 'L�'.C�l; I--�7 --1-t t..'�I� � T� along or across Counry Road No. �� (from,at) ��C t �n ,. ��"� Cr `-��"� �� to C�'�'S� -(uA;eT.��i ) Applicant M P11 A.�-t c�.r.�.. S�m M c. MQ.�uS ,4ddress /9/0 �i�n�c,�c1��hLa�. �j-D»�, M N SS.3g/ _ Phone �(�)Z.) 4'71-7��5 24 HR. Emergency Phone �to�Z) �7/�7.2 7s FrXNo. ��01�-) 3�Z-�og7� SUBMIT A CHECK PAYABLE TO "HENNEPIN COUNTY TREASURER". SUBMIT TWO (2) COPIES OF ENGINEERING DRAWINGS FOLDED TO 8 1/2" x 11". 1.TYPE OF CONSTRUCTION ❑ Underground ❑ Aerial Other 2.TYPE OF UNDERGROUND CONDUIT /�, Size Depth Size Depth �17 ❑ Multiduct ❑ Iron ❑ Plastic !� Copper ❑ Concrete ❑ Cable ❑ Steel ❑ 3. METHOD OF INSTALLING UNDER ROADBEDS (Other) � j� ❑ Boring-Jacking- Pneumagopher(48"minimum depth) �� 1 Casing-Carrier Pipe required for aIl installations exceeding 4 inches in diameter. � Open Cut-Call PERMIT OFFICE prior to making application. 4.AREA TO BE DISTURBED TRAVELED SURFACE SHOULDER BOULEVARD r Concrete ❑ Curb &Gutter C Bituminous ❑ Culverts �;,Sod ❑ Trees/Shrubs � Bituminous ❑ Sidewalk ❑ Gravel ❑ Field Grass � Other 5. All work done under this permit, including restoration,will be completed on or before —[��-T�lY/�- �99�(�� Date If work cannot be completed within dates specified, a written request for permission of extension must be made to Hennepin County Transportation Department. If a request fior extension is not made prior to the expiration of the Permit as noted in Line 5 above, the Permit shall become null and void on the expiration date. The Permittee agrees to defend, indemnify and hold harmless the County, its officials, officers, employees and agents from any liability,claims,causes of action,judgements or expenses, including reasonable attorneys'fees, resulting directly or indirectly from any act or omission of the Permittee, its subcontractors, anyone directly or indirectly employed by them and/or anyone for whose acts and/or omissions they may be liable, arising out of the work to be done under this Permit. and against all loss by reason of the failure of the Permittee to perform fully, in any respect, all obligations under this Permit. Permittee herewith accepts the terms and conditions of the regulations as laid down by the Counry and agrees to fully comply therewith to the satisfaction of the Hennepin County Transportation �epartment. I Organization ,�Z`�/3�C.�ll�r�'L By(Print Name) l�ef�ik. l�L��[� Date � Z �L�9�' PRIOR TO STARTING � CONSTRUCTION, CALL Signature y�?_�� 1�,(Ly.1(,�d_— (612) 745-7600 APPL/CATION W/LL 6E REJECTED/F NOT S/GNED BY AEPRESENTATIVE AUTHOR/ZED TO B/ND APPLICANT TO ALL TERMS AND COND/TIONS CONTA/NED HEREIN.