Fillable APPLICATION FOR ROW/STREET EXCAVATION PERMIT (City of Jordan, MN)

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APPLICATION FOR ROW/STREET EXCAVATION PERMIT (City of Jordan, MN)

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The APPLICATION FOR ROW/STREET EXCAVATION PERMIT (City of Jordan, MN) form is 2 pages long and contains:

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  • 16 other fields

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File type: PDF

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City of Jordan – Application for Street Excavation Permit Last Updated 8/27/2020 Page 1
APPLICATION FOR ROW/STREET EXCAVATION PERMIT
CITY OF JORDAN
210 EAST FIRST STREET
JORDAN, MN 55352
952-492-2535
Site Information
Site Address: _________________________________________________________________________________
Legal Description: _____________________________________________________________________________
Applicant / Contractor Information
Name: ______________________________________________ Phone: __________________________________
Address: ______________________________________________ Email: _________________________________
Owner Information ([ ] Check if same as above)
Name: ________________________________________________ Phone: ________________________________
Address: ______________________________________________ Email: _________________________________
Fee is $150.00 per permit and a letter of credit in the amount of the City of Jordan’s estimated cost of
restoration work. Please submit payment and letter of credit with the application.
1. Purpose of Work: _______________________________________________________________________
______________________________________________________________________________________
2. Date Commencement begins: _________________
3. Date Completed: _____________
Note: Responsible representatives of the individual or firm must review the following general conditions and
initial each item pertaining to the proposed work. You must also provide a letter of credit or deposit in the
amount equal to the City of Jordan’s estimated cost of restorative work.
1. The City must be notified prior to the commencement of the work. ( )
2. Posting party is responsible for complying with all OSHA and Minnesota Dept. of Transportation employee and
roadway safety standards. ( )
3. Underground utility installation placed within the roadway right-of-way must be inspected by a member of the
Public Works Department or the City Engineer prior to backfill of the trench.( )
4. Underground utility installation placed within private property must be inspected by the City’s Building Inspector
prior to backfill of the trench. ( )
5. Backfill material must be inspected by a member of the Public Works Department of the City Engineer. The
inspector must be present upon commencement of the backfill of material. ( )
6. Type, quality and thickness of base and pavement structure places within the roadway patch area (including
driveways, trails and sidewalks) must conform to standards set by the Public Works Department and the City
Engineers. ( )
City of Jordan – Application for Street Excavation Permit Last Updated 8/27/2020 Page 2
7. If roadway patch is required, posting party must place pavement under inspection of a member of the Public
Works Department. ( )
8. Failure to comply with items 1 through 7 may result in the repetition of the construction project to the
satisfaction of the City or assignment of the restoration to a competent party with subsequent costs to come from
the letter of credit. Any costs above and beyond the letter of credit will be billed and paid for by the applicant.
Note: By signing below, the posting party (or responsible representative) acknowledges reviewing and
understanding the intent of each item initialed by the party.
I, the undersigned, herewith accept the conditions of the City of Jordan under Ordinance 96, Section 96:05,
Street Openings or Excavations, and agree to comply with the city code to the satisfaction of the City of Jordan.
I certify that all information submitted is true and correct.
Applicant Signature: ______________________________________ Date: _____________________
Owners’ Signature(s):_______________________________________ Date: _____________________
For Office use only:
Date: ______________ Fee Paid: __________________
City Approval: ________________________________ Date: _____________________
Public Works Approval: _________________________ Date: _____________________
City Engineer’s Approval: ________________________ Date: ______________________
Letter of Credit Amount: _________________________
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APPLICATION FOR ROWSTREET EXCAVATION PERMIT (City of Jordan, MN)

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Completed 9 February 2021

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