Permit to Work Within City Property/Right-of-Way

Type of Work to be Completed

Public UtilityPrivate Utility

Location

Description of Work

Please indicate and items that will be affected/disturbed in conjunction with work (check all that apply)

Method of Installation/Construction

Planned Start Date

Planned Completion Date

Name*

Phone*

Email*

example@example.com

Fax

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Representative

Phone

Email

Name

Phone

Email

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

On-Site Supervisor

Phone

Site plan MUST be included with application, for requirements see Excavation Code - Policy Statement

File Upload

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The Permitee(s) agree to hold the City harmless from any and all damages claimed by reason of negligence, incompetence or mission on the part of such person, firm or corporation in the performance of their work, the same to include but not limited to careless guarding of excavations made by them or failure to restore all public properties to as good as condition as they were before such work was done or for any damages growing out of the negligence or carelessness of such licensed person, firm or corporation. The Permitee(s) agrees to warrant the work in accordance with City Ordinance #162. Gopher One-Call registration number is required, please notify City Hall if permit is approved.*

I Agree

Signature*

Clear

Date*

Date

Gopher One-call #:

User Registration ApprovedSite Plan Included

Date Received:

Authorization of Permit

In consideration of agreement to comly in all respects with the regulations and codes of teh City of Glyndon covering such operations, and pursuant to authorization duly given by the said City, permission is hearby granted for the work to be done as described in the above application with said work to be done in accordance with special provisions as hearby stated:

Approved By:

Date:

Permit #:

Start Date:

Completion Date:

Fee:

Paid

Inspection Completed By (Initial):

Attached Traffic or Sidewalk Detour Plan:

YesNo

Permit to Work Within City Property/Right-of-Way

Applicant Information

Party or Organization Performing Work

FOR OFFICE USE ONLY