HomeMy WebLinkAbout3-Right-of-way Excavation Permit ApplicationExcavation Permit Application for work in the City Right-of-Way or Easement September 2012
PERMIT NO.
CITY OF LAKE ELMO
3880 Laverne Avenue North
Lake Elmo, Minnesota 55042
Phone: 651.747.3900
RIGHT-OF-WAY OR CITY EASEMENT
EXCAVATION PERMIT APPLICATION
Name and Address of Utility Owner: Name and Address of Party Performing Work:
Contact: Contact:
Phone: Phone:
24-Hour Emergency Phone:
Email address:
24-Hour Emergency Phone:
Email address:
1. Nature of Work: Gas Main Telephone Main Cable Main Electric Main
Gas Service Telephone Service Cable Service Electric Service
Other
Type of Surface to be Disturbed: Gravel Bituminous Concrete Boulevard
2.Location (House No., Street, Nearest Intersection, Development Name):
(Attach 5 copies of scaled drawings showing accurate right-of-way information, topographic information, and planned installation.)
3. Size and kind of pipe, conduit or cable:
Length of pipe, conduit or cable:Depth from Surface:
Dimensions of Excavation:
4. Method of Installation or Construction (including method of compaction and excavation)
5. Work to start on or after and to be completed on or before
6.Will detouring of traffic be necessary? Yes No If so, describe routing:
For
(Applicant)
Signed By
Dated
The date when the work is completed must be reported to the City of Lake Elmo.