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PERMIT APPLICATION Excavations and Obstructions in Public Right-of-Way (City of Golden Valley)

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BROWSE CITY OF GOLDEN VALLEY (MN) FORMS

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Physical Development—Engineering | 7800 Golden Valley Road, Golden Valley, MN 55427-4588
763-593-8030 | TTY: 763-593-3968 | www.goldenvalleymn.gov | publicworksdept@goldenvalleymn.gov
PERMIT APPLICATION
Location Of Work/Address
Applicant/Contractor Contact Person
Address City State ZIP 24-Hour Phone
Work Phone Cell/Pager Fax Email
Property Owner (if dierent than above) Contact Person
Address City State ZIP 24-Hour Phone
Work Phone Cell/Pager Fax Email
Start Date End Date
(includes full
restoration)
☐ ☐ Excavation ☐☐ Joint Application ☐☐ Temporary Access
☐ ☐ Permanent Obstruction ☐☐ Temporary Obstruction
Applicant’s Project #
Work Type (check all that apply)
☐ ☐ Berm
☐ ☐ City Project Construction
☐ ☐ Crane
☐ ☐ Culvert
☐ ☐ Drain Tile
☐ ☐ Driveways
☐ ☐ Dumpster, Container, POD
☐ ☐ Fences (above ground)
☐ ☐ Fences (buried, invisible)
☐ ☐ Inow & Inltration Sewer
☐ ☐ Irrigation
☐ ☐ Landscaping
☐ ☐ Parking Lot
☐ ☐ Private Utilities
☐ ☐ Retaining Wall
☐ ☐ Sanitary Sewer
☐ ☐ Sidewalk
☐ ☐ Special Event/Parade
☐ ☐ Storm Sewer
☐ ☐ Sump Drain Connection
☐ ☐ Trailer, Equipment
☐ ☐ Trees
☐ ☐ Water Main
☐ ☐ Wireless Facility
☐ ☐ Other: ________________
Facility Information (check all that apply) Purpose Disturbed Surfaces Replacement Surfaces
☐ ☐ Buried Cable
☐ ☐ Cable TV
☐ ☐ Carrier Conduit
☐ ☐ Electric
☐ ☐ Fiber Optic
☐ ☐ High Pressure Gas
☐ ☐ Low Pressure Gas
☐ ☐ Main
☐ ☐ Overhead Utility
☐ ☐ Power Pole
☐ ☐ Service
☐ ☐ Sewer Liner
☐ ☐ Telecommunications
☐ ☐ Other: ________________
☐ ☐ Abandon in Place
☐ ☐ Cut-O
☐ ☐ New
☐ ☐ Remove
☐ ☐ Repair
☐ ☐ Replacement
☐ ☐ Other:________________
☐ ☐ Bituminous
☐ ☐ Concrete
☐ ☐ Dirt
☐ ☐ Gravel
☐ ☐ Trees/Shrubs
☐ ☐ Turf
☐ ☐ Other: _____________
☐ ☐ Bituminous
☐ ☐ Concrete
☐ ☐ Dirt
☐ ☐ Gravel
☐ ☐ Trees/Shrubs
☐ ☐ Turf
☐ ☐ Other:___________
Excavation Size Excavation Method
Number of Openings: _______
Total Lineal Feet: ________
Length: _______ Width: ________
Depth: ________
☐ ☐ Augering
☐ ☐ Core Drill
☐ ☐ Direct Bury
☐ ☐ Directional Bore
☐ ☐ Hand Dig
☐ ☐ Hole
☐ ☐ Jacking
☐ ☐ Open Trench
☐ ☐ Plow
☐ ☐ Pneumagopher
☐ ☐ Splice Pit
☐ ☐ Other: _____________
FEES
☐ ☐ $200 per Blvd Opening ☐☐$400 per Paved Opening (includes curb alterations) ☐☐ $150 per Permanent Obstruction (includes courtesy benches)
☐ ☐ $125 per Driveway ☐☐ $50 per Temporary Access ☐☐ No Charge per Overhead Utility Repair ☐☐ $100 per Temporary Obstruction
☐ ☐ Underground Utility Fee, 0-100 ft = $250 + $1.50/ft ☐☐ Underground Utility Fee, over 100 ft = $400 + $1/ft over 100 ft
☐ ☐ No Charge per Service Drop (meeting conditions set forth in Master Fee Schedule) ☐☐ No Charge per Franchise Agreement
Excavations and Obstructions in Public Right-of-Way
APPLIED DATE EXPIRATION DATE PERMIT
☐ ☐ Approved ☐ ☐ Denied
SIGNATURE DATE
☐ ☐ Plan attached ☐ ☐ Detail Plates attached ☐ ☐ Special Provisions attached ☐ ☐ As-Built Required
PERMIT FEE Amount:________________
Fee Paid:
☐ ☐ Yes ☐ ☐ No ☐ ☐ Invoiced Check #: ________________
SECURITY Amount:____________________
Security Provided: ☐ ☐ Yes ☐ ☐ No Check #: ________________
CERTIFICATE OF INSURANCE
☐ ☐ Yes ☐ ☐ No $5,000 LICENSE AND PERMIT BOND ☐ ☐ Yes ☐ ☐ No
continued
Repair
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Pertinent Regulations
SAFETY
1) All warning devices and barricades shall conform
to the Minnesota Manual on Uniform Trac
Control Devices.
2) All warning devices barricades, agmen, and
equipment shall be provided by parties or organi-
zations performing the work.
3) All warning devices and barricades shall be
placed according to provisions in the most recent
edition of the MMUTCD (Minnesota Manual on
Uniform Trac Control Devices).
4) All warning devices and barricades and safety
vests shall be kept clean and in good repair at all
times.
5) Advance warning of detours, approved by the
Golden Valley Director of Public Works, shall be
posted no less than ve working days before the
detour is placed.
6) Excavation shall be cribbed, sheeted, and/or
fenced when necessary, or as required by the City
of Golden Valley.
7) Inclement weather shall be reason for delay of
the project start or suspension of the project as
determined by the City of Golden Valley.
OPERATIONS
8) Permit on Job: Permits or copies shall be kept
on the site of the work while it is in progress in
the custody of the individual in charge and shall
be exhibited upon request made by any City
ocial.
9) Provisions and Specications: These general
provisions and specications shall be considered
as forming an integral part of each and every
permit issued for operations on city roads. The
work authorized by this permit shall be done
at such time and in such manner as shall be
consistent with the safety of the public and shall
conform to all requirements and standards of
the City of Golden Valley as herein specied. If at
any time it shall be found by the City of Golden
Valley that the work is not being or has not been
properly performed, the permittee, upon being
notied, shall immediately take the necessary
steps, at their own expense, to place the work
in condition to conform to said requirements or
standards.
10) Annulment: In the event of willful failure or
neglect by said permittee or their employees
to perform and comply with the prescribed
conditions, restrictions, and regulations, Golden
Valley Public Works may revoke and annul this
permit and order said permittee to remove any
and all structures or property belonging to said
permittee from the legal limits of the highway or
City property. In the event the permittee leaves
the highway in a condition needing repair or
construction, the Golden Valley Public Works may
repair such highway and the costs of such repair
or construction shall be paid by the permittee.
11) Execution: The permittee shall use diligence in
the execution of the work authorized under this
permit in order not to endanger or unneces-
sarily obstruct travel along the said roadway.
Operations shall be so conducted at all times as
to permit safe and reasonably free travel over
the roads within the limits of the work herein
prescribed. All safety measures for the free move-
ment of trac shall be provided by the permittee
at their own cost.
12) Conformity to Laws: The installation shall be
made in conformity with all applicable laws,
regulations, and codes covering said installa-
tions. All installations shall be made in confor-
mity with regulations of governmental agencies
for the protection of the public.
13) Removal: If at any time the permitted structure
or facility shall fall from any cause whatsoever,
the permittee shall have the same removed or
repaired within 48 hours after receipt of written
notice to do so, unless by reason of some ex-
traordinary happening the City of Golden Valley
may extend such time limits.
14) Existing Facilities: Applicant must protect all
existing installations.
15) Private Property: The Permit as issued does
not in any way imply an easement on private
property.
16) Damage to Roadway: If pavement or roadway
is damaged, same shall be restored to its original
or better condition, at the sole expense of the
permittee, according to the specications and
directions of the City of Golden Valley.
17) Quality of Work: Finished surface, base, and
sub-base of road upon completion of work shall
be equal to or better than specications for
original road.
18) Cutting Trees: The permission herein granted
does not confer upon the permittee the right
to cut, remove, or destroy trees or shrubbery
within the legal limits of the roadway or relieve
permittee from obtaining any consent other-
wise required from the owner of the property
adjacent thereto.
19) Boring or Jacking: Installation of pipe under
roadways shall be jacked or bored as designated
by Golden Valley Public Works.
20) Liner or Casing Pipe: Shall be required for instal-
lations exceeding 4 inches in diameter.
21) Pressure Grouting: Shall be required as desig-
nated by Golden Valley Public Works.
22) Drainage: All waterways and lines of drainage
shall remain operative.
23) Pole Anchors: No pole anchors, anchors, braces,
or other construction shall be placed on right-of-
way except by permit authorization.
24) Driving Limitations: It is prohibited to drive
onto roadway from ditch or on shoulders or over
curbs where damage will occur.
25) Lugs on Equipment: No lugs shall be used on
equipment traversing road, which will damage
the road surface.
26) Clean-up: Street surface and roadside shall be
kept clean, neat, and presentable throughout
construction as determined by Golden Valley
Public Works.
27) Dust Control/Street Sweeping: Shall be
provided, at no cost to the City, upon request of
Golden Valley Public Works.
28) Trees and Vegetation: Burning or disking opera-
tions and/or the use of chemicals to control or
kill trees, brush, and other vegetation is prohib-
ited without advance approval from the City.
29) Restoration: It shall be further understood that
the permittee will be responsible for mainte-
nance of any failures due to settlement, erosion,
lack of vegetation growth, rutting, or other job-
related problems for three years after completion
of project and Notice of Completion of work has
been received by the City of Golden Valley.
30) Manholes: All manholes, shut-o valve covers,
etc, shall be placed 1/2 inch lower than nished
grade.
Signature
All work done under this permit, including
restoration, must be completed within the dates
specied. Requests for extensions must be made
in writing to Golden Valley Public Works before the
Permit expiration date, when the Permit becomes
null and void. Except for negligent acts of the
City, its agents, and its employees, the Utility or
Permittee shall assume all liability for and save the
City, its agents, and its employees, harmless from
any and all claims for personal injuries, including
death, for damages to tangible, real, or personal
property, actions, or causes of action arising out of
the work to be done herein and the continuing uses
by the Permittee, including but not limited to the
placing, constructing, reconstructing, maintaining,
and using of said utility under this application and
Permit for construction.
I (We) the undersigned, herewith accept the terms
and conditions of the regulations as laid down by
the City of Golden Valley and agree to fully comply
therewith to the satisfaction of the City of Golden
Valley. Individuals(s) representing the City of
Golden Valley have the legal authority to bind the
applicant to all terms, conditions, and provisions
contained herein.
Applicant’s Name (Please Print) Applicant’s Signature
X
Date
Before starting construction, call 763-593-8030.
Excavations and Obstructions in Public Right-of-Way Permit Application Page 2 of 2
3/19
This document is available in alternate formats upon a 72-hour request. Please call 763-593-8006
(TTY: 763-593-3968) to make a request. Examples of alternate formats may include large print,
electronic, Braille, audiocassette, etc.
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PERMIT APPLICATION Excavations and Obstructions in Public Right-of-Way (City of Golden Valley)

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Completed 3 August 2020

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