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Permit No.: . ApPLICATION FOR RIGHT-OF-WAY PERMIT CITY OF MOUNDS VIEW, 2401 HIGHWAY 10 MOUNDS VIEW, MN 55112 (653)717 -4052 DExcavation Permit DObstruction Permit Applicant: GSOC Reg. #: Street Address: City: State: Zip: Contact Person: Work Phone: Fax: 24 Hour#: I Cell Phone: Pager #: E-Mail: General Contractor (if other than applicant): Fax: Work Phone: 24 Hour #: Cell Phone: Pager #: GSOC Reg. #: Location and Description (Closest Street Address): Facilities Information: 0 Cable 0 Cooling 0 Electric 0 Fiber 0 Gas 0 Heating 0 High Pressure 0 Low Pressure 0 Sewer 0 Telecomm 0 Traffic 0 Water 0 Other: Purpose of Construction o New 0 Replacement 0 Repair o Other: Type of Construction 0 Aerial 0 Bore 0 Chamber 0 Hole o Plow 0 Trench o Other: Construction Details Excavation size: Length: Width: Depth: ROW being used: 0 Driving Lane 0 Parking Lane 0 Sidewalk 0 Boulevard o Utility Easement Type of material: 0 Concrete 0 Bituminous 0 Gravel 0 Sod o Field Grass 0 Trees 0 Shrubs Structures: 0 Curb & Gutter 0 Sidewalk o Signals 0 Other Shoulders: 0 Bituminous 0 Gravel o Road Signs 0 Culvert o Other Construction Schedule Estimated Starting Dates: Estimated Ending Dates: I, We, the undersigned, herewith accept the terms and conditions of the rules and regulations of the City of Mounds View and agree to fully comply therewith to the satisfaction of the City. _he applicant in carrying on any and all of the work above mentioned or referred to in its application and in the Permit issued herefore, shall trictJy conform to the terms of such Permit, and the regulations of the City of Mounds View. The applicant shall also comply with the egulations of all other governmental agencies and perform the work in a manner that will not be detrimental to the right-of-way and that will safeguard the public. Applicant's Signature: Date: