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C'1TK aF <br /> HC 5138' � OFaNO� <br /> � <br /> . HENNEPIN COUNTY � `�, ,�.-=',(Y�'i�J�� <br /> � DEPARTMENT OF TRANSPORTATION '" `'' "� y <br /> 320 Washington Avenue South <br /> � - Hopkins, Minnesota 55343 <br /> APPLICATION FOR INSTALLATION OF UTILITIES�(j�, 2� 5� ��9�� <br /> County Road No.�.� Permit No. 2`iR55 <br /> Municipality <br /> LOCATION AND/OR DESCRIPTION OF WORK Application is hereby made for permission to place, construct and thereafter <br /> maintain a .;:�•: :.,, �,�:�zV7Cr. <br /> along or across County Highway No. 51 (from, at) ": ;�t(; Pt;i.i�- d'P ;jl 35 ;�c3k"'�� Si;ft�r: ;_�k i VF: <br /> Stit���-�� alat:i� to SULLT�i4�ESTEN Y ��'•� TtL P�i�Y�'F�TY <br /> NAME of applicant l�t��rHF�S j�l�;;� � Phone G7�-3343 <br /> Address S�(15�'i�.Ftt) i�a c �,. �:.ks ` 5533� <br /> city state zip co e <br /> Party or organization performing work =�'��' �ti�'w <br /> Address SA.`:E AS r1:';;::�'. <br /> city state zip code <br /> Phone (Business) �.��5�' � 'i 41t3-3343 Phone (Emergency) <br /> 1. TYPE OF CONSTRUCTION —Submit five copies of detailed print showing type and location of installation. <br /> ❑s Underground ❑ Aerial ❑ Other <br /> 2. TYPE OF UNDERGROUND CONDUIT <br /> Size Depth Size Depth <br /> ❑ Multiduct ❑ Iron <br /> ❑ Plastic ❑ Copper <br /> ❑ Concrete ❑ Cable <br /> ❑ Steel ❑ <br /> other <br /> 3. METHOD OF INSTALLING UNDER ROADBEDS <br /> ❑ Boring—Jacking—Pneumagopher <br /> ❑ Casing—Required for all conduit exceeding 4 inches in diameter <br /> ❑ Open Cut—Explain why necessary <br /> 4. AREA TO BE DISTURBED " <br /> TRAVELEDSURFACE SHOULDER BOULEVARD <br /> ❑ Concrete ❑ Bituminous ❑ Sod <br /> ❑ Bituminous ❑ Gravel � Field Grass <br /> STRUCTURES <br /> ❑ Curb&Gutter ❑ Culverts ❑ Trees <br /> ❑ Sidewalk ❑ Road Signs ❑ Shrubs <br /> ❑ Signals ❑ Other <br /> 5. All work under this permit wil I be completed on or before i.:.���/�.7 <br /> Date <br /> (PERMIT IS VOID AFTER THIS DATE) <br /> If work cannot be completed within dates specified,a written request for permission of extension must be made to the Hennepin County <br /> Department of Transportation. <br /> Except for the negligent acts of the County, its agents and its employees,the Utility or Permittee shall assume all liability tor and save the County, <br /> its agents and its employees, harmless from any and all claims for damages,actions or causes of action arising out of the work to be done herein and <br /> the continuing uses by the Permittee, including but not limited to the placing,constructing, reconstructing, maintaining and using of said utility <br /> under this application and Permit for construction. <br /> (1, We) the undersigned, herewith accept the terms and conditions of the regulations as laid down by the County of Hennepin and agree to fully <br /> comply therewith to the satisfactio�of the Hennepin County Department of Transportation. <br /> Organization ! �.;`t `. ' t x. <br /> By Date ts118/95 <br /> �^+f�. <br /> � <br />