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<br />('-,.~-- ANNUAL RIGHT-OF-WAY USER 1425 Paul Kirkwold Drive
<br />~~.'~~ REGISTRATION FORM: :\nl,~'Jl Hills, M~ 5~112 .
<br />~ I<,\MSEY COU NTY 6) 1-266-7186 of!.ce
<br />, DI~l~Al~TrvlJ~,N?' OF Pl~BLI~: _W(;[<J~Sp , ') 651-266-'/188 fax
<br />Ri>.MSFY COONIY Phone: (b51) 2hl)-! 100 l' ax (h:) 1.) ,~6IJ- / ] 00
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<br />Type Registrdtion: NcwkJ Al1l1lul r Ipt/aleLI
<br />,'-, Ulili~y 9\~ncrrJ,,; ('ontrador[.\l
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<br />RegIstrants ame: ! I( \ I '--. (, ,C~ h',-p/ <.J
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<br />Company Name: /;'Jri! ,r/~: \ /.'. J/' //~ '-, !
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<br />Gopher One-Call Registration Ccrtif.icate Number.. ,
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<br />Busincss Phonc Number.,...
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<br />Enicrgency Phone Number ..,
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<br />AtTACHMENTS: I
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<br />Certificate of ,lJ:tsuran:cc: (See Ramsey County, Insurance and Indemniflcatioll Rtquin:mellls) i
<br />1. A copy of Ramsey Counties "Jnsurance Requirements" can he downloaded from our web site. !
<br />2. Attach a copy of your "eERTJ FICATE OF INSURANCE" to application. I
<br />3.R.a,mscy County, their officials and employees mllst be named as "additional insured" on the II
<br />,i~~1J!~I1<>e-&ertificate. ' .." "'--- -.. -..,. ,
<br />Construction Perforil1ancc Bond: I
<br />I. "ANNUAL": Utility owners must post an Annual Constmction Performance Bond in the amount of I
<br />$100-,_000, (we reserve the right to increase this amountfi:,Jr larger projects). Attach to application_ I
<br />2, "INI>IVIPUAL llROJECT BONDS": All other Pcdimnance Bonds (individual project l>()nds)
<br />and amounts shall be determined at the timc of the pennit application. 'Ibe amount of the bond will
<br />bedeterrnil1edby several,factors, including age of road, slIrt:1,ce to be djsturQ~.9-, w!c:!!..h_- lengt4 ~
<br />depth of excavation, etc, Th<.: length of this bond shall be for a period of twenty-four (24) months, i
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<br />Annual Right-or-Way Uscr Registration Fee: $25_00 Check:;gr BiJledD
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<br />Applicant! /.h~-- ~~~-;7 r I. 7 /" - J --./_
<br />Simlature~ tni'('./ "":,/?//CV Date: /1' t.._ & _..a.u
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<br />Authorized Coun;11tepr~sentative: ,''-', ," Registration NumUer: ~" .
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