Right-of-Way Permit Right-of-Way Permit Application
5959 Main Avenue
P.O. Box 9 Date Received
N1bertville Albertville, MN 55301 Date Notified
S-11 T,,aA- LiMmS. Si,Cit,,Lif- Phone: 763-497-3384 Fax: 763-497-3210 Date Paid
------------------------------------------------------------------------- Check#/Cash
Project Location: Permit#
The Applicant is: Owner Contractor
Right-of-Way Permit Fees
Utility Owner:
Name Address Registration Fee
City St Zip
' Phone (W) (C) Excavation Permit Fee
Fax Email '
Gopher One Call Registration Certificate No. Obstruction Permit Fee
Contractor: Permit Extension Fee
Name Address
City St Zip Delay Penalty
Phone (W) (C) '
Fax Email TOTAL
Gopher One Call Registration Certificate No.
Local Contact:
Name Cell Phone Interdepartmental Review
*Note: Local contact must be available 24 hours per day.
Dept Date Approved
Policy number on Certificate of Insurance or Self-Insurance
**Note: See attachment for requirements Engineer
Type of Work:
Public
Begin Date: End Date: Works
Description of Work: (Length & Location
Other
Estimated Valuation of Work:
I hereby certify that I have read and examined the application and understand that all work which is
being performed shall comply with the approved plans and specifications submitted. All provisions of
laws and ordinances governing this type of work will be complied with whether specified herein or not.
Avnlicant's Printed Name Amlicant's Signature Date
-------------------------------------------------------------------------
Approved by Public Works Supervisor Date
Final Inspection Date: Pass or Fail
Public Works Supervisor Signature
Performance Bond/Escrow Amount:
Special Conditions or Comments:
1
A�Ibcrtvillf.
Small°'IIl"moiun Wing.Big Ciao We.
Right-of-Way Permit Application
Certificate of Insurance or Self-Insurance Requirements
The following insurance requirements shall apply:
1. The insurance policy shall be issued to the registrant by an insurance company licensed to do business in
the State of Minnesota, or a form of self-insurance acceptable to the City of Albertville.
2. The registrant shall be insured against claims for personal injury, including death, as well as claims for
property damage arising out of the: a) use and occupancy of the right-of-way by the registrant, its
officers, agents, employees and permittees; and b) placement and use of facilities and equipment in the
right-of-way by the registrant, its officers, agents, employees and permittees, including, but not limited
to,protection against liability arising from completed operations, damage of underground facilities and
collapse of property.
3. The City and its agents shall be listed as an additional insured as to whom the Coverage's required
herein are in force and applicable and for whom defense will be provided as to all such Coverage's.
4. The City shall be notified thirty (30) days in advance of cancellation of the policy or material
modification of a coverage term.
5. The following insurance Coverage's shall be required:
• Comprehensive General Liability Insurance $1,000,000
(Combined single limit, including bodily liability and property damage liability)
• Worker's Compensation Insurance and Employees' Liability Insurance $1,000,000
(Combined single limit, including bodily injury, sickness, disease and death liability)
• Automobile, Bodily Injury and Property Damage Liability Insurance $1,000,000
(Combined single limit bodily injury and property damage liability)
The policy shall be a standard form policy provided for by a carrier approved by the State of Minnesota
and having an "AM BEST" ratings of A- and FSC VIII or better. The policies shall not contain any
exclusions that will restrict coverage on any operations performed.
CITY OF ALBERTVILLE 5959 MAIN AVENUE NE 763.497.3384 X103
BUILDING DEPARTMENT ALBERTVILLE,MN 55301 WWW.CI.ALBERTVILLE.MN.US
2