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   CITY OF COON RAPIDS

   2023 RIGHT-OF-WAY USE REGISTRATION 

7. Disclaimer

   Each person who occupies, uses, or seeks to occupy or use the right-of-way or any equipment located in the right-of-way, including by lese, sublease or assignment, or who has, or seeks to have, equipment located in any right-of-way must register with the City. Registration must be completed before permit applications will be reviewed or work can be performed in the right-of-way.

9. Registrant Info

   THE REGISTRANT IS: (Select One)

   1. UTILTY OWNER

   1. CONTRACTOR

   1. PROPERTY OWNER

13. UTILITY COMPANY:

15. Company Name: 

16. Co Name

18. Gopher State One Call registration certificate number:

19. Gopher number

21. Local Representatives Name:

22. Local rep

24. Office Address:

25. Office Address
27. City
28. State
29. ZIP
31. Email
32. Phone Number

36. CONTRACTOR NAME:

37. Contractor
39. Address:
40. Address
42. City
43. State
44. Zip
46. Email
47. Phone Number
51. PROPERTY OWNER NAME:
52. Property Owner
54. Address
55. Address
57. City
58. State
59. Zip
61. Email
62. Phone Number

66. PLEASE INCLUDE THE FOLLOWING DOCUMENTS:

    1 - Certificate Of Insurance or self insurance naming the City as an additional insured. 

    2 -  "Restoration Bond" means of a performance bond or letter of credit posted to ensure the availability of sufficient funds to assure that Right-of-Way excavation and obstruction work is timely and properly completed and shall be sufficient to restore the Right-of-Way.

68. By signing this, applicant certifies they have read and understand the right-of-way ordinance.  Keep all the information listed above current at all times by notifying the City of changes within 15 days.   

70. Authorized Signature:
71. Date
73. Files:
74. Files:

76. Please Upload:

    1. Certificate of Insurance or self insurance naming the City as an additional insured

    2. "Restoration Bond"/performance bond or letter of credit 

Leave This Blank:


78. 1. Receive an email copy of this form.
79. Email address

    This field is not part of the form submission.

80. Submit Submit and Print

* indicates a required field