CITY OF DETROIT LAKES

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					                                            CITY OF DETROIT LAKES
              APPLICATION FOR A LICENSE TO EXCAVATE IN RIGHT-OF-WAY

Registrant’s Name: ___________________________________________________________________
Registrant’s Agency: __________________________________________________________________
Agency Mailing Address: _______________________________________________________________
Business Phone Number: ____________________________              Fax Number: _____________________________
Emergency Phone Number: __________________________               e-mail Address: ___________________________
Gopher One-Call Registration Certificate Number: ___________________________________________
Local Representative (24 hour Contact) Information (if applicable)
        Name: _______________________________________________________________________
        Business Phone Number: ____________________            Emergency Phone Number: ____________________
        Mobile Number: _______________________________
Certificate of Insurance or Self-Insurance: (See City Right of Way Ordinance: Section 302.06)
        Name of Insurance Company: _____________________________________________________________
        Policy Number: _______________________________
        Copies Required:         Yes             No _____
Insurance Company Agency
        Agency Name: _________________________________________________________________________
        Personal Injury coverage amount:                  $_________________________
        Property Damage coverage amount:                  $_________________________
        Worker’s Compensation coverage amount:            $__________________              _

Surety Bond Company:                                                 Bond#:
        Copy Included (must be an excavation bond): Yes              No     Company will send directly
Authorized Signature: __         _______________________          ___Title: __________________

        In order to get your excavator's license this form must be filled out and returned to the Public Works Dept.
        508 E. Front Street, Detroit Lakes, MN 56501, along with:
                * $100.00 Excavation License Fee
                * Excavation Surety Bond in the amount of $5,000
                * Copies of your Liability and Worker's Compensation Insurance in the amount of $1,000,000

An Excavation Permit is required each time a licensed contractor excavates in a public right-of-way.
An Excavation Permit must be filled out and $100 permit fee paid before any digging begins.


  OFFICE USE ONLY

  City of Detroit Lakes Authorized Representative:    Bradley Green, Public Works Director

          Signature: ________________________________

          Date:      ________________________________

          License Number assigned: ___________________            Check #

				
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