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REGISTRATION APPLICATION <br /><City Name> Department of Public Works <br />Address <br />Phone: <br />Web Site: <br />Fax E -Mall: <br />:.�i t.. ,�e:%\ „\ ,.. P .. 'Y,. ' "e'�Z' .>tWfl`'. <br />:'\ �� �R .�Gr%,I�Ei;�tj��;i�.�,.• a: \� fit: �,. � G.�=L r`,,. T <br />Please check wether you will be the Owner of r Fqulpmnnt Owner <br />cc p New Apporant <br />equipment placed In the ROW or a contractor j^I CnntrnMnr <br />Are you a new applicant <br />updating information? 31 Llpdatn of Information <br />wishing to work in the ROW. If other please <br />1'1 Other (Fzpinln) <br />explain in next section. <br />\ �� II GAS o (O <br />c ' <br />, . . e' \ irt 9O, E <br />>t <br />i. �i . . . .4t p = <br />other in Registration Type please explain below <br />If you checked <br />Name <br />ddr•s• <br />City Stale Zip Code <br />Fax Number E-Mail Address <br />Phone Number <br />V '>� .. ....... a 'a`,w•t4Tfi21Y• >Ma <br />+r�i�, `��'�.3t'�\;�,v�sE.,j3� ` rfJt�», �Ssil�irifor) 5te2ioti�` {tt %�,�A�PIIo�kfke }>h .� ., , s rt;�>;��'q$` x��i�`x+a>'�•�?�'�t` <br />�.. <br />ID Number (II Contractor) <br />Operator Registration Number <br />>, \ \\a Rfi\ R\�\ r iii. \S•S .wit <br />v �..\c� ; \d »ry t. i3Ptil?StE1i7I� <br />5 ttl i � s. Z � \ \\ Ot GSIG\h ..k »»>` aW 19 ' Y>A = °ti' •Y �i.� 6 # t =Y)�) H 0 47 Di <br />p� t� r, t �`' Y v <br />wLYfS. c. Y�\ylY \. �v3°aa \h \ \�, i! 1�.d t�fa4iafiE�p P�tOD14 tiles ;4nptp� y) »hero i °"xboq wY @YH r..+i5;`(v nyfi?;);Ys(nr'. <br />%'£,.• R•... .. ....... v • :.r, des, .. .. .... ..:.::: .... <br />_ ........ <br />Name <br />Address <br />City State Zip Cods <br />_ <br />Fax Number E-Mail Address <br />Phone Number <br />'t �(b 'V ♦ : V1i <F �'i \i >FK' i ”( \'liT 2•@•. ii»x Mr"a K <br />k � \ �''6 �\ \ 1�.2 Fs MA., "'>�\ ee b r`�' 9u: �°.�. >.`.rP sa �"' tt 5� i�i. 4.... S. . <br />Name Phone Number Pager Fax Number <br />�SF D ', \ < \`,.Y.�t;� tkV �\ U FtTfA'tV!'fi E.lii>w? \M %l gg%grf>Y Yea \'<SeXH. .. .1 :. �. <br />Please attach copies of certificates and licenses as required for registration <br />1) Certificate of Insurance <br />2) Certificate of Incorporation (If Incorportated) <br />3) Certificate of Authority from Minnesota Public UUIUes Commision (MPUC) <br />4) Removal Bond (Equipment Owner Only) <br />5) Minnesota Contractors License <br />tli r *` .z:4: �. *.,y zir\.t 0 0. ice E g t.t.'f' ' <br />Date received Date Approved <br />Registration Number Assigned Registered by Whom <br />3/5/97 <br />Page 93 <br />