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r+cs,ss�vss> HENNEPIN COUNTY ` <br /> DEPARTMENT OF PUBLIC WORKS � <br /> �;� PERMIT FEE _$50.00 320 Washington Avenue South <br /> ` Hopkins, Minnesota 55343 � <br /> � (612)930-2550 ? 1`�`�t� <br /> �� APPLICATION FOR INSTALLATION OF UTI�ES = <br /> ;� � <br /> County Road No. Permit Na � <br /> Municipaliry � <br /> � <br /> LOCATION AND/OR DESCRIPTION OF WORK Application is hereby made for permission to place, construct and thereafter a' <br /> � <br /> maintain a <br /> along or across County Highway No. (from, at) � <br /> to <br /> Applicant _ , ,i;Y; <br /> Address ` G F:t,a:� , �� , ` , <br /> . � ...�:,�.:��.-..�.�.�....:�.�+��"�. � ` . , � � � <br /> Phone - Phone(Emergency) <br /> Party or organization performing work Env i t�1 '' ?': � I nc. <br /> Add ress �r�� C• i�o tn;:u t.;�t :,ti� :._ :: , S� i :_ _ , _ <br /> Phone(Business) ��1� � ��1���� �� Phone(Emergency)� �'� <br /> � <br /> 1.TYPE OF CONSTRUCTION -Submit five copies of detailed print showing type and location of installation. ;€ <br /> � Underground �� �'��� ❑ Aerial ❑ Other ' <br /> 4: 5 <br /> 2.TYPE OF UNDERGROUND CONDUIT � <br />�. 2 <br /> Size Depth Size Depth � <br />�< ❑ Multiduct ❑ Iron " <br />� ❑ Plastic ❑ Copper ;� <br />� ❑ Concrete ❑ Cable � <br /> p Steel "' S' ❑ <br /> ',� <br /> f�" 2' (other) ' <br /> �. •�;�-:. �; <br /> 3. METHOD OF INSTALLING UNDER ROADBEDS <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 SHOULDER BOULEVARD <br /> ❑ Concrete ❑ Bituminous ❑ Sod <br /> ❑ Bituminous ❑ Gravel Q Field Grass <br /> STRUCTURES <br /> ❑ Curb&Gutter ❑ Culverts ❑ Trees <br /> ❑ Sidewalk ❑ Road Signs ❑ Shrubs :� <br />;; ❑ Signals ❑ Other 3 <br /> 5.All work done under this permit, including restoration,will be completed on or before —`�' J <br />�'M ^,ate � <br />�` If work cannot be com leted within dates s ecified,a weitten re uest for ermission of extension must be made to Henne in Count De artment of Public Works. If a � <br /> r% P p 4 p P Y P <br /> request for extension is not made prior to the expiretion of the Permit,the Permit shall become null and void on the expiration date. c� <br /> `� <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 County,its agents and its employees, q <br /> harmless from any and all claims for damages,actions or causes of action arising out of the work to be done herein and the continuing uses by the Permittee,including but "i <br /> k� not limited to the placing,constructing,reconstructing,maintaining and using of said utility under this application and Permit for construction. <br /> g (I,We)the undersigned, herewith accept the terms and conditions of the regulations as laid down by the County of Hennepin and agree io fully comply therewith to the ,� <br /> satisfaction of the Hennepin County Department of Public Works. <br /> PRIOR TO STARTING "�r����� '_:r�:;rt-.eet �-��= `.��.�.ir..1 =:,:�.� c;-.. ; <br /> Organization ; <br />� CONSTRUCTION� CALL By(Print Name) F�• �rY ��� Date �; <br />�" 930-2550 s�9�at��e � � <br /> _ � <br />� . <br />