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City of Elk River <br /> 13065 Orono Parkway <br />Elk River, MN 55330 <br />Telephone: 763/441-7420 <br />Fax: 763/441-7425 <br /> <br />APPLICATION FOR STREET DISRUPTION PERMITS <br /> <br />Excavation <br /> <br />[--]Obstruction <br /> <br />E] Attached Plan Submitted by (Applicant): <br /> Joint Application (Company Names): <br /> <br />GSOC Registration #: Plan #: I Project #: II <br />Location: <br />From and To (Address/Location): ~ <br /> <br />Applicant: 24 Hour Phone: <br />Address: <br />City: State: Zip: <br />Contact Person: Work #: 24 Hour #: <br />Cell Phone #: Pager #: <br /> <br />General Contractor: <br /> <br />Contact Person; <br />Sub Contractor #1: <br />Sub Contractor #2: <br /> <br /> GSOC Registration #: <br />Work #: 24 Hour #: <br />Home #: Pager/Cell #: <br /> GSOC Registration #: <br /> GSOC Registration #: <br /> <br />Cable TV I I Cooling Traffic <br />Gas: High Pressure Low Pressure <br /> <br />Telecomm. It Fiber I I Other <br /> <br />Water <br /> <br />Sewer <br /> <br />Conduit (Size & Kind): <br /> <br />Cable (Size & Type): <br /> <br />Excavation Size: <br /> <br />Length: Width: Depth: <br /> <br />Total Linear Footaqe Installed: <br /> <br />Ty.n~ nf M~t~ri~l' <br />Rfrll~l'Hr~' <br />Shoulders: Bituminous Gravel Road Signs Culvert Other <br /> <br />Estimated Starting Dates: Weekend Dates: <br />Estimated Ending Dates: After Hour Dates: <br /> Date Received: <br /> <br />Applicant's Signature: <br /> Date: <br /> <br />Review Committee: <br /> <br />Approval Date: <br /> <br />Permit Number: <br /> <br />Yes <br /> <br />S:\PLANNING\FORMS\ROWFORM.DOC <br /> <br /> <br />