HomeMy WebLinkAbout2-Right-of-way Registration ApplicationRegistration Application Page 1 of 2 September 2012
CITY OF LAKE ELMO
3880 Laverne Avenue North
Lake Elmo, Minnesota 55042
Phone: 651.747.3900
RIGHT-OF-WAY REGISTRATION APPLICATION
Are you a new Applicant or updating information New Applicant Update of Information
REGISTRATION INFORMATION (Company Information)
Name:
Address:
City: State: Zip Code:
Phone: Fax No. Email:
GOPHER STATE ONE CALL INFORMATION (If Applicable)
Operator Registration No.: ID No.:
LOCAL REPRESENTATIVE (Person Responsible for Fulfilling Obligations of Registrant)
Name:
Address:
City: State: Zip Code:
Phone: Fax No. Email:
Contact No. 1 Contact No. 2 Contact No. 3
Name:
Phone No.:
Pager No.:
Fax No.:
Registration Application Page 2 of 2 September 2012
CITY OF LAKE ELMO
3880 Laverne Avenue North
Lake Elmo, Minnesota 55042
Phone: 651.747.3900
RIGHT-OF-WAY REGISTRATION APPLICATION
INSURANCE (Companies holding franchises with the City need not provide insurance certificates if previously provided.)
Please attach copies of insurance certificates from a company authorized to do business in the State of Minnesota in the following
amounts. The City of Lake Elmo shall be listed as additionally insured on insurance certificates.
1.GENERAL LIABILITY:Public liability, including premises, products and complete operations.
1) Bodily Injury Liability $1,000,000 each person
$3,000,000 each occurrence
2) Property Damage Liability or $3,000,000 each occurrence
3) Bodily Injury and Property $3,000,000 single limit
Damage Combined
2.COMPREHENSIVE:Automobile Liability Insurance, including owned, non-owned and hired
vehicles
1) Bodily Injury Liability $1,000,000 each person
$3,000,000 each occurrence
2) Property Damage Liability or $3,000,000 each occurrence
3) Bodily Injury and Property $3,000,000 single limit
Damage Combined
3.Such Certificate shall verify that the Registrant is insured against claims for personal injury, including death, as well as claims for
property damage arising out of (i) use and occupancy of the right-of-way by the registrant, its officers, agents, employees, and
permittees, and (ii) placement and use of equipment or facilities in the right-of-way by the registrant, its officers, agents,
employees and permittees, including but not limited to, protection against liability arising from completed operations, damage of
underground equipment and collapse of property. Such certificate shall also name the City as an additional insured as to whom
the coverages required herein are in force and applicable and for whom defense will be provided as to all such coverage. Such
certificate shall require that the Director be notified 30 days prior to cancellation of the policy.
SIGNATURE OF REGISTRANT
By
Its
Date
ACKNOWLEDGEMENT OF INDEMNIFICATION
The Applicant hereby acknowledges the indemnification as provided by the applicable section of the City Code.
(NOTE: This acknowledgement need not be provided by a company holding a franchise with the City)
By
$5,000 SECURITY (ESCROW) VERIFIED Its
Date