2. Project Description*
4. Contact email*
6. Name of Applicant*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Contact Person*
15. Office Phone*
16. Cell Phone*
18. Name of Contractor Performing Work*
20. Address*
22. City*
23. State*
24. Zip Code*
26. Contact Person*
27. Office Phone*
28. Cell Phone*
30. Applicant is responsible for all locations and Gopher State One Calls (including registration of new utility). Please describe and check all that apply. Attach one scale drawing of the project area. The drawing will show all existing and proposed right-of-way, curb, sidealk, trails, above and below ground facilities or appurtenances, and poles.
    
    Excavation Contractor must meet all City and MPCA Environmental and Sediment Control ordinances/policies at all times. Failure to do so may result in fines or revocation of permit.
32. Scale drawing*
34. Nature of work (check all that apply)*

    1. Cable TV
    2. Sewer
    3. Repair
    4. Other

    1. Electric
    2. Water
    3. Abandon

    1. Gas
    2. New
    3. Underground

    1. Telecommunications
    2. Replace
    3. Aerial

    If other, please describe below
36. Description of other (nature of work)
38. Type of Surface to be Disturbed*

    1. Gravel
    2. Easement

    1. Concrete
    2. Bituminous

    1. Trail
    2. Boulevard

    1. Sidewalk
    2. Other (signs, tress, etc)

    If other, please describe below
40. Description of other (type of surface to be disturbed)
42. Location (address or cross street)*
44. Size and Type of pipe, conduit, or cable
46. Voltage or Pressure
47. Length
48. Depth from surface
50. Distance from curb or centerline
51. Clearance on pole
53. Method of Installation*

    1. Trench
    2. Pneuma Gopher

    1. Plow
    2. Hand Dig

    1. Directional Bore
    2. Other

    1. Backhoe

    If other, please describe below
55. Description of other (method of installation)
57. Estimated Start Date*
58. Estimated Ending Date
60. Will detouring of traffic be necessary? (Traffic control must comply with MMUTCD)*

    1. Yes

    1. No
62. Restoration Planned (All restoration must be in-kind)*

    1. Bituminous Paving
    2. Hand Formed Curb or Sidewalk w/Forms

    1. Motorized Tamper (Compaction)
    2. Sodding w/4" Topsoil

    1. Machine Formed Curb
    2. Seeding w/4" Topsoil
64. Permits are issued subject to all the terms, conditions and requirements of Section 800 of the Brainerd City Code. By executing this application and accepting the permit, the Applicant agrees to fully comply with all terms, conditions and requirements of Section 800 of the Brainerd City Code.
66. *Signature*
    *Actual signature (not electronic) will be required on the City's permit document
67. Date*
69. Once your permit has been approved by the City, you will receive an email with your permit number, which is required for online payments. Payment can then be made at the City's webstore, in person at City Hall, or with a check through the mail.
73. Fees
    Linear Utility Projects - $45.00 each separate excavation (i.e. handholes, trenches) and $.035 cents more per foot for boring/trenching/Pneuma Gopher lengths in excess of 100 feet.
    
    Residential Excavation - $45.00 each separate excavation (properties serving 4 or less housing units
    
    Commercial Excavation - $70.00 each separate excavation (commercial properties or residential properties serving more than 4 housing units)
    
    Sewer/Water Line - Residential - $45.00 each separate excavation + $40.00 each connection (properties serving 4 or less housing units)
    
    Sewer/Water Line - Commercial - $70.00 each separate excavation + $70.00 each connection (commercial properties or residential properties serving more than 4 housing units)
77. Date Received
78. Permit Fee
79. Permit Number
81. Approved By
82. Approved Date
84. Existing Street Age

    1. 0-5 years

    1. 5 years to 5 year CIP

    1. 5 year CIP
86. Conditions of Approval
88. All work including restoration was completed on (date) and is ready for final inspection
89. Signature
    Sign when all work is completed
91. Payment
    City of Brainerd Webstore

    The following link can be used for making payments online.
Leave This Blank:


93. 1. Receive an email copy of this form.
94. Email address

    This field is not part of the form submission.

95. Submit

* indicates a required field