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• HC 5136 <br /> HENNEPIN COUNTY <br /> DEPARTMENT OF TRANSPORTATION <br /> 320 Washington Avenue South <br /> Hopkins, Minnesota 55343 - , _, <br /> APPLICATION FOR INSTALLATION OF UTILITIES ,. � <br /> �. .� _, � <br /> � . <br /> County Road No. Permit Na <br /> Municipality - <br /> LOCATION AND/OR DESCRIPTION OF WORK Application is hereby made for permission to place, construct and thereafter <br /> maintain a <br /> along or across County Highway No. (from, at) <br /> to <br /> NAME of applicant Phone <br /> Address <br /> city state zip co e <br /> Party or organization performing work <br /> Address <br /> city state zip code ��`-, <br /> Phone (Business) Phone (Emergency) :x <br /> � <br /> 1. TYPE OF CONSTRUCTION —Submit five copies of detailed print showing type and location of installation. ,. :`R <br /> ❑ Underground ❑ Aerial ❑ Other <br /> ; . <br /> 2. TYPE OF UNDERGROUND CONDUIT <br /> Size Depth Size Depth <br /> ❑ Multiduct ❑ Iron <br /> ❑ Plastic ❑ Copper <br /> ❑ Concrete ❑ Cable � <br /> ❑ Steei ❑ <br /> other <br /> 3. METHOO 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 /> ❑ Sidewaik ❑ Road Signs ❑ Shrubs <br /> ❑ Signals ❑ Other <br /> 5. All work under this permit will be completed on or before <br /> Date <br /> �, <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 /> � � � � � �.*��,�.; <br /> ,,. <br /> _ , w. <br />�, <br /> � _._. ., _.� . �., <br />