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Hf;5133(9/O6� • � Permit <br /> PERMIT FEES � �� ���p �, No. ��q?_3 <br /> MUNICIPALITY = $50.00 Transportation Department ` (,` <br /> Operations Dlvision - Permit Office �pl� County �� <br /> ALL OTHERS = $75.Q0 1600 Prairie Drive-Medina, Minnesota 55340-5421 Road No. <br /> PhOne: (763)745-7600 FAX: (763)478-4002 �MUNlCIPALITY <br /> PERMIT APPLICAT/DN FOR UTILITY CONSTRUCTION I OROI�a <br /> LOCATION AND/OR DESCRIPTION OF WOqK:Applicatfon is hereby made for permis n to piace,construct and thereafter mainta(n a <br /> J c }etL �E tc,� �2 l.J C�� " � '�d <br /> along or across Counry Road No. � (from,at) N J <br /> to <br /> Applicant `— C�L� s`► E. , �,r .Tt�.�c+R. <br /> Address � � � 1�l �� <br /> Phone (�1�.1 Ll��� ���l�l � �''131. 61�`�4I- Gl�� 24 HR. Emergency Phone � ) �$ <br /> FAX No. � � <br /> SUBMIT A CHECK PAYABLE TO "HENNEPlN COUNTY TREASURER". <br /> SUBMIT TWO (2} COPIES OF ENGINEERING DRAWINGS FOLDED TO 8 1/2" x 11". <br /> 1. TYPE OF CONSTRUCTION <br /> ❑ Underground O Aerial �her <br /> 2. TYPE OF UNDERGROUND CONDUIT — <br /> Size Depth Size Depth � <br /> ❑ Multiduct ❑ Iron <br /> � Piastic ❑ Copper <br /> � Concrete � ❑ Cable <br /> ❑ Steet ❑ <br /> 3. METHOD OF INSTALLING UNDER ROADBEDS �other) <br /> ❑ Boring-Jacking-Pneumagopher(48"minimum depth) <br /> ❑ Casing-Carrier Pipe required for all installations exceeding 4 inches in diameter. <br /> ❑ Open Cut-Call PERMIT OFFICE prior to making application. <br /> 4. AREA TO BE DISTURBED <br /> '` TRAVELED SURFACE SHOULDER BOULEVARD <br /> � Concrete ❑ Curb&Gutter ❑ Bituminous O Culverts ❑ Sod ❑ Trees/Shrubs <br /> ❑ Bituminous ❑ Sidewalk ❑ Gravel �Field Grass O Other <br /> 5. AI work done under this permit, including restoration,will be completed on or before __—______.___Ul�S_�� (Z�_ _ <br /> oace <br /> If work ,r`ar�hot be completed within dates specified, a written request for permission of extension must be made fo Hennepin County <br /> Transportation Department. If a request for extension is not made prior to the expiration of the Permit as noted in Line 5 above, the <br /> Permit shall become nuil and void on the expiration date. <br /> The Permittee agrees to defend, indemnify, and hold harmless the County, its otficials, offlcers, employees, and agents from any <br /> liability, claims, causes of action, judgements, or expenses, including reasonable attomeys' fees, resulting directly or indirectfy from <br /> any act or omission ot the Permittee, its subcontractors, anyone directly or indirectly employed by them, and/or anyone for whose acts <br /> and/or omissions they may be liable, aris(ng out of the work to be done under this Permlt, and against all loss by reason of the failure <br /> of the Permittee to perform fully, in any respect, alf obligations under this Permit. Permittee herewith accepts the terms and conditlons <br /> of the regulations as laid down by the Counry and agrees to fully comply therewith to he satisfaction ot the Hennepin County <br /> Transportation Department. <br /> Organization • ��� <br /> PR/OR TO STARTING BY(Print Name) � Date <br /> CONSTRUCTION, CALL Signature <br /> /7r+'�1 7d�i_7ri/)n APPLICA N L R CTED!F NOT SIGNED BY REPRESENTATIVE AIJTHORIZE�' <br />