10.1 SR 02-21-2023 - Laserfiche WebLink

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Legal Description of Address and/Street: Description of Start and End Point : Detailed description of work: Utility Type: ❑ Cable/Phone ❑ Gas ❑ Electric ❑ Other Method of Construction: ❑ Trench ❑ Bore ❑ Aerial ❑ Hole ❑ Chamber ❑ Plow ❑ Other Note: Installation of utilities deeper than 48 inches is prohibited without specific approval from the City of Elk River. Will construction disrupt the street surface*: � Yes Q No Will construction disrupt City sidewalks and/or trails*: Q Yes � No *If yes, a Street Barricade Plan and/or Repair Plan must be attached Construction Schedule: Estimated Start Date: Estimated Ending Date: (Maximum 90 day window) * iVlust call 2 business da�rs prior to beginiung construction * *** If woik has not begun within 45 da�rs of estimated start date, this permit is null and void *** Required Submittals for Permit: ■ Two sets of plans to scale ■ If applicable, Street Baericade and Street Repaie Plans ■ �5,000 Escrow in favor of the Citv of Elk River ■ Name(s) and proof of Gopher State Training (minimum one person per crew required) If a Facility is Hit: ■ Evacuate the area if a dangerous situation has been created ■ Call 911 on all faciiinr hits ■ Call the utilitv vou hit Special Provision Required by the City of Elk River: Erosion control BMP's (inlet protecrion, etc) must be used during the project. Disiupted soils must be stabilized immediately upon completion of the project. ---------------- This is an application for a permit — It is not valid until processed I hereby appl� for a Street Disruption permit, and I acknowledge that the information above is complete and accurate. I understand tlus is not a permit and work is not to start without a permit. I herebp agree to conform strictl� to the provisions of the Citn of Elk River Code of Orclinances Section 1200 and applicable Nlinnesota State Statute, whether or not specified in the perinit, together with special provisions required by the Cit� in the perinit issued. I understand that failure to adhere to these provisions is grounds for re�ocation of the permit. A copy of this permit shall be present on the job site whenever work is being conducted Signature of Contractor/Responsible Party Print Name Date Signature of Authorizing City Official & Title Print Name Date