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

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

Permit Fee - $50.00
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)

WaterCurb & GutterTreePond/Drainage StructureSanitary SewerStreet SurfaceVegetation/GrassStreet LightStorm SewerSidewalk/Bike PathSign/Traffic Control DevicePrivate Utility (electric, gas, etc.)
Method of Installation/Construction
Planned Start Date
Planned Completion Date
Applicant Information
Name*
Phone*
Email*
example@example.com
Fax
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Representative
Phone
Email
Party or Organization Performing Work
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

Cancelof
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*

MonthDayYear
Date
FOR OFFICE USE ONLY
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
City Hall: 36 3rd Street SE | PO Box 223 | Glyndon, MN 56547 | www.glyndonmn.com | 218-498-2578 | Fax: 218-498-2579
Should be Empty:

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

Applicant Information

Party or Organization Performing Work

FOR OFFICE USE ONLY