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r <br />HC51J6(12<’97> <br />PERMIT FEES <br />MUNICIPALITY = $50.00 <br />ALL OTHERS = $75.00 <br />HENNEPIN COUNTY DEPARTMENT OF PUBLIC WORKS <br />Transportation Division - Permit Office <br />320 Washington Avenue South - Hopkins, Minnesota 55343 <br />Phone:(612)930-2550 FAX: (612)930-2727 <br />County • <br />Municipality __________________Road No.' <br />LOCATION AND/OR DESCRIPTION OF WORK: Application Is hereby made for permission to place, construct and thereafter maintain a <br />/{T 5vK.>^cy / yz <br />(^aion^or across County Highway No__/(from, at)_______________________________________________________ <br />to______________________________________________________________________________ <br />Applicant <br />Address . <br />Phone _Phone (Emergency) <br />FAX No. <br />1. TYPE OF CONSTRUCTION - Submit two copies of detailed print showing type and location of installation. <br />□ Underground □ Aerial □ Other <br />2. TYPE OF UNDERGROUND CONDUIT <br />Size Depth <br />□ Multiduct ____________ ____ <br />□ Plastic ______________ _____ <br />□ Concrete ______________ ____ <br />□ Steel_____________________ <br />Size Depth <br />3. METHOD OF INSTALLING UNDER ROADBEDS <br />□ Iron <br />□ Copper <br />□ Cable□ __ <br />(Other) <br />□ Boring - Jacking - Pneumagopher (48" minimum depth) <br />□ Casing > Carrier Pipe required for all installations exceeding 4 inches in diameter. <br />□ Open Cut - Explain why necessary_____________________________________ <br />4. AREA TO BE DISTURBED <br />TRAVELED SURFACE <br />□ Concrete <br />□ Bituminous <br />STRUCTURES <br />□ Curb & Gutter <br />□ Sidewalk <br />□ Signals <br />SHOULDER <br />□ Bituminous <br />□ Gravel <br />□ Culverts <br />□ Road Signs <br />□ Other____ <br />BOULEVARD <br />□ Sod <br />□ Field Grass <br />□ Trees <br />□ Shrubs <br />5. All work done under this permit, including restoration, will be completed on or before <br />Oait <br />If work cannot be completed within dates specified, a written request for permission of extension must be made to Hennepin County <br />Department of Public Works. If a request for extension is not made prior to the expiration of the Permit, the Permit shall become null <br />and void on the expiration date. <br />Except for negligent acts of the County, its agents and its employees, the Utility or Permittee shall assume all liability for and save the <br />County, its agents and its employees, harmless from any and all claims for damages, actions or causes of action arising out of the work <br />to be done herein and the continuing uses by the Permittee, including but not limited to the placing, constructing, reconstructing, <br />maintaining and using of said utility under this application and Permit for construction. <br />(I, We) the undersigned, herewith accept the terms and conditions of the regulations as laid down by the County of Hennepin and <br />agree to fully comply therev/ith to the satisfaction of the Hennepin County Department of Public Works. <br />PRIOR TO STARTING <br />CONSTRUCTION, CALL <br />930-2550 <br />Organization <br />By (Print Name) <br />Signature____ <br />Date