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<br />State Plumbers License: <br /> <br />YES <br /> <br />NO <br /> <br /> <br /> <br />STREET DISRUPTION OR UTILITY HOOK-UP PERMIT <br /> <br />Name of Company or Corporation: <br /> <br />Name of individual making application: <br /> <br />Company Address: <br /> <br />Company Phone: <br /> <br />The aforementioned hereby requests permission to disrupt the <br />public right-of-way , and agrees <br />to replace all materials and street surfacing according to the <br />specifications and under the supervision of the Street <br />Superintendent of the City of Elk River. Applicant must also <br />call for appropriate inspections. <br /> <br />TYPE OF WORK: <br />Sewer <br />Water <br />Street Disruption <br />Other <br /> <br />. <br /> <br />INSURANCE Each applicant shall accompany his application <br />with a certificate of insurance. Such certificate shall <br />specifically state that such insurance covers underground <br />operations and shall contain a provision that the coverage <br />afforded under the policies will not be cancelled or materially <br />changed until at least 15 days prior written notice has been <br />given to the City. <br /> <br />Insurance Company: <br /> <br />Insurance Company Address: <br /> <br />Coverage: $250,000 per person <br /> <br />$100,000 per occurrence <br /> <br />$ 10,000 per property damage <br /> <br />$ 2,000 Letter of Credit in Favor of the City of Elk <br />River <br /> <br />Date: <br />(,. Signed: <br /> <br />720 Dodge Avenue N.W., Elk River, Minnesota 55330 (612) 441-7420 <br />