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<br />RAMSEY COUNTY <br /> <br />ANNUAL RIGHT-OF-WAY USER <br />REGISTRATION FORM <br />RAMSEY COUNTY <br />DEPARTMENT OF PUBLIC WORKS <br />Phone: (651) 484-9104 Fax (651) 482-5232 <br />http://www.co.ramsev.mn.us/pw <br />email: P\\.Pcrmitsii)co.ramsev.mn.us <br /> <br />3377 North Rice Street <br />Shoreview, MN 551. <br />651-482-52390ffiW <br />651-482-5232 fax <br /> <br />.. <br />, <br /> <br />Type Registration: NewD Annual UpdateD <br /> Utility OwnerD ContractorD <br />Registrants Name: <br />Company Name: <br />Registrants Billing Address: Street: <br /> City: State: Zip: <br />E-Mail Address ............... <br />Business Phone Number.... <br />Emergency Phone Number. <br />Facsimile Number............ <br />Gopher One-Call Registration Certificate Number... <br />Local Representative (24-hour contact) Information: (minimum of two names) <br />Name ........................... <br />Business Phone Number..... <br />Emergency Phone Number ... ~ <br />Pager Number .................. <br />Cell-Phone Number........... <br /> <br />ATTACHMENTS: <br />Certificate of Insurance: (See Ramsey County, Insurance and Indemnification Requirements) <br />1. A copy of Ramsey Counties "Insurance Requirements" can be downloaded from our web site. <br />2. Attach a copy of your "CERTIFICATE OF INSURANCE" to application. <br />3. Ramsey County, their officials and employees must be named as "additional insured" on the <br />insurance certificate. <br />Construction Performance Bond: <br />1. "ANNUAL": Utility owners must post an Annual Construction Performance Bond in the amount of <br />$100,000 (we reserve the right to increase this amount for larger projects). Attach to application. <br />2. "INDIVIDUAL PROJECT BONDS": All other Performance Bonds (individual project bonds) <br />and amounts shall be determined at the time of the permit application. The amount of the bond will <br />be determined by several factors, including age of road, surface to be disturbed, width - length - <br />depth of excavation, etc. The length of this bond shall be for a period of twenty-four (24) months. <br /> <br />Annual Right-of-Way User Registration Fee: $25.00 <br /> <br />Cash D <br /> <br />Check D <br /> <br />BilledD <br /> <br />Applicant <br />Signature: <br /> <br />Date: <br /> <br />(MUST BE SIGNED) <br /> <br />Official Use Only <br /> <br />Authorized County Representative: <br /> <br />Registration Number: <br /> <br />Signature: <br /> <br />Date: <br />