HomeMy WebLinkAbout5-Right-of-way Obstruction Permit ApplicationObstruction Permit Application in the City Right-of-Way or City 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
OBSTRUCTION PERMIT APPLICATION
Name and Address of Permit Applicant: Name and Address of Party Performing Work:
Contact:
Phone:
24-Hour Emergency Phone:
Email address:
Contact:
Phone:
24-Hour Emergency Phone:
Email address:
1.Nature of Work:
Type of Surface to be Disturbed: Gravel Bituminous Concrete Boulevard
2. Location (House No., Street, and Nearest Intersection):
(Attach 5 copies of scaled drawings showing accurate right-of-way information, topographic information, and planned installation.)
3. Method of Construction or Installation:
4. Work to start on or after and to be completed on or before
5. 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.