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HC 5136 HENNEPIN COUNTY <br /> v, DEPARTMENT OF TRANSPORTATION <br /> 320 Washington Avenue South <br /> Hopkins,Minnesota 55343 <br /> APPLICATION FOR INSTALLATION OF UTILITIES <br /> County Road Nold Permit No. 22671 <br /> Municipality <br /> LOCATION AND/OR DESCRIPTION OF WORK Application is hereby made for permission to place, construct and thereafter <br /> maintain a /c/Z_e- <br /> along efeeross County Highway No. 19 (from,at) X00 5_v e,7,01' Or G Aff <br /> to <br /> NAME of applicant �� -�Ofi /�� Phone 0/7L-80017 <br /> Address o?VO A44?2f S /�•�' D,C.pivD l/llit/ S::'J'6y <br /> city state zip co e <br /> Party or organization performing work <br /> Address city state zip code <br /> Phone (Business) <br /> Phone(Emergency) �17Z —$00 7 <br /> 1. TYPE OF CONSTRUCTION—Submit five copies of detailed print showing type and location of installation. <br /> ❑ 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 ❑ other <br /> 3. METHOD OF INSTALLING UNDER ROADBEDS <br /> ❑ Boring—Jacking—Pneumagopher ,( )/� <br /> ❑ Casing—Required for all conduit exceeding 4 inches in diameter l V <br /> ❑ Open Cut—Explain why necessary <br /> 4. AREA TO BE DISTURBED <br /> TRAVELED SURFACE SHOULDER BOULEVARD <br /> ❑ Concrete ❑ Bituminous �❑( Sod <br /> 11 Bituminous E3 Gravel J1 Field Grass <br /> STRUCTURES <br /> ❑ Curb&Gutter ❑ Culverts ❑ Trees <br /> ❑ Sidewalk ❑ Road Signs ❑ Shrubs <br /> ❑ Signals ❑ Other <br /> 5. All work under this permit will be completed on or before 9-1— 9 <br /> 11 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 for 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 /> (I,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 satisfaction of the Hennepin County Department of Transportation. <br /> Organization <br /> By Date �� <br />