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5.1. HRSR 10-04-2004
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5.1. HRSR 10-04-2004
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6/11/2015 4:53:51 PM
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City Government
type
HRSR
date
10/4/2004
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• <br /> PERMIT <br /> City of oqU a t-0-7 <br /> • Elk • <br /> ve r <br /> SEWER & WATER HOOK-UP PERMIT <br /> • <br /> 13065 Orono Parkway • <br /> Elk River,MN 55330 <br /> • <br /> NAME OF COMPANY OR CORPOR,TION ?. \/C7 S <br /> NAME OF INDIVIDUAL MAIHNGAPPLICATION:V' ,T� <br /> CO.YIFANYADDR.ESS: PHONE: <br /> • <br /> THE AFOREMENTIONED HEREBY REQUESTS PERMISSION TO DISRUPT THE <br /> PUBLIC RIGHT-.0E-WAY �Pi`J ,AND AGREES TO <br /> REPLACE ALL MATERIALS A.N STREET SURFACING ACCORDING TO THE <br /> SPECIFICATIONS AND UNDER TIE SUPERVISION OF THE STREET • <br /> • SUPERINTENDENT OF THE CITY OF ELK RIVER. APPLICANT MUST ALSO CALL <br /> FOR APPROPRIATE INSPECTIONS. <br /> JOB SITE: <br /> TYPE OF WORK: <br /> SEWER WATER <br /> INSURANCE <br /> EACH APPLICANT SHALL ACCOMPANY HIS APPLICATION WITH A CERTIFICATE OF <br /> INSURANCE. SUCH CERTIFICATE SHALL L SPECIFICA.LY STATE THAT SUCH - <br /> LNSURA NCE COVERS UNDERGROUND OPERATIONS AND SHALL CONTAIN A <br /> • PROVISION THAT THE COVERAGE AFFORDED UNDER TEE POLICES WILL NOT BE <br /> CANCELED OR MATERLAT,T,Y CHANGED UNTIL AT T. &ST'15 DAYS PRIOR WRITTEN <br /> NOTICE HAS BEEN GIVEN TO THE CITY. <br /> INSURANCE COMPANY/ADDRESS: • <br /> • <br /> COVERAGE : <br /> $1,000,000 PER OCCURRENCE BODILY INJURY <br /> $1,000,000 PER PROPERTY DAMAGE • <br /> $1,000,000 GENERAL AGGREGATE <br /> $1,000,000 PRODUCTS AND COMPLETED OPERATIONS AGGREATE <br /> $ 2,000 BOND IN FAVOR OF THE CITY OF ELK RIVER <br /> STATE PLUMBERS LICENSE: YES NO <br /> DATE: P_..kt/: 647 / - <br /> SIGNED:ellIMICKAILEN - . <br /> NOTE: <br /> • NO PERSON SHALL NLAKE CONNECTIONS OF ROOF DOWNSPOUTS,EXTERIOR FOUNDATIONS <br /> DRALN1S,AREA-WAY DRAINS OR OTHER SOURCE OF SURFACE RUNOFF OR GROUNDWATER TO <br /> A BUILDING SEWER OR BUILDING DRAY WHICH IN TURN IS CONNECTED DIRECTLY OR <br /> INDIRECTLY TO A PUBLIC SANITARY SEWER <br /> • UNUSED SEPTIC TANKS,CESSPOOLS,LEACHING PITS AND SIMILAR DEVICES AND <br /> STRUCTURES SHALL BE BACIUILLED OR MADE SAFE AND UNUSABLE IN A MANNER <br /> ACCEPTABLE TO THE CITY. <br /> FPPROVED BY: DATE: Q <br /> • <br /> S: units\STREET <br />
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