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NENNEPIN COUNTY <br />HIGHWAY DEPARTMENT � �r <br />720 Washington Av•nw South <br />Hopkins, Mmnnesoto 55317 t <br />APPLICATION FOR INSTALLATION OF UTILITIES <br />County Rood No. — _ _ 15 <br />VILLAGE OF ORONO <br />Permit No. <br />Municipality iaYrrre " i�YP .i r• <br />LOCATION AND/OR DESCRIPTIQN OF WORK Application is herebv made for pernn�o►titsion to ►1 XX1l"AjrJ; maintain a <br />buried telephone c:' lv on <br />�WWI "W'JAXCounty Highway Ne. 15 AU! at) lame tVenut) �- <br />re <br />NAME of applicant 'wrthaestera Sell Telephonei1+&n - Phone 932-6377 <br />Address 553.' County 'otlt_le 'rt,Lh Il'1i. '111nesots <br />CITY ST ATE ZIP CODE <br />Pasty or or7oni�az�fatien performing work __C'rt)1Nt'Sit)rn �T*1!!2 Otr' <br />.nqt! ..mirls, <br />Address J7.af Guftt OA%i 1' S0'.;Ct: tr r�.l''i nt'm`$Otl! ei <br />- — -x - ----- -- -- — ---�- --- -- — <br />CIT. jTATE ZIP COOL <br />' none (Bus•ness) — -__ _ *harts l(,.nergemY) <br />1. AERIAL CONSTRUCTION Submit detared print showinq tops anS omtlon at Installation <br />2. UNDERGROUND CONSTRUCTION <br />44_ '1'• <br />CONDUIT <br />INSTALLATION! <br />CASING <br />(] Multi duct the <br />Pipe class — - <br />Steel pipe <br />❑ Transite <br />Type bedding <br />Other type <br />Clay or concrete <br />Service type <br />Size <br />(7 Steel, cast or plastic <br />Size * <br />Depth <br />Other _ <br />Depth <br />3. METHOD OF INSTALLING UNDER ROADBEDS III open trench, explain why necessary) <br />Boxing ❑ lacking <br />4. AREA TO BE nl;,rURSED <br />TRAVELEDSURFACE <br />❑ Concrete <br />[] Bituminous <br />Other _-- --_- <br />STRUCTURES <br />U Bridge <br />J Box culvert <br />❑ Pipe (Concrete, meta!) <br />tunrrr nce <br />Bituminous <br />r Grovel <br />Other <br />❑ Curb & Gutter <br />❑ Sidewalk <br />Other <br />❑ Open trench <br />BOULEVARD <br />❑ Sed <br />❑ field Gross <br />Other <br />❑ Trees <br />[] shrubs <br />(] Plantings <br />5. The surface will be restored and all work under this permit will be completed on or before ____ Conf 1 n-1 ng <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 <br />County Highway Department. <br />Excell (or the negligent acts of the County, its agents and Its employees, the Utility or Permittee shall assume all liability lot and <br />save the County, its agents and its employees, harmless from any and all rloims for damages, actions or causes of action arising <br />out of the work to be done herein and the continuing uses by the Permittee, including but not limited to the placing, constructing, <br />reconstructing, maintomnirg and using of said utility 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 <br />agree to fully comply therewith to the satisfaction of the County Highway Department. <br />'ort►t.t.ii oll Tnlen`ione 'c-^lny <br />Organization <br />Date --- <br />rr � � <br />