HomeMy WebLinkAboutCredit River Substation - Excavating & Filling Permit
4646 Dakota Street S.E.
Prior Lake, MN 55372-1714
October 9,2009
Chris Rogers
Xcel Energy
414 Nicollet Mall, 4th Floor
MP-8
Minneapolis, MN 55401
RE: LETTER OF ACCEPTANCE AND PROJECT CLOSE OUT
CREDIT RIVER SUBSTATION
Dear Mr. Rogers:
The restoration associated with the Credit River Substation is complete. Attached please
find the original bond for the work. This officially closes out this project, if you have any
questions or concerns, please call me at 952-447-9832.
Si~,
~p~
Assistant City Engineer
CITY OF PRIOR LAKE
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G'\Permlts\F:xcavat11l~ Fllhlli\closeout letter 100 e 1 tV rub.
Phone 952.447.9800 / Fax 952.447.4245
Bond 190006359
LICENSE OR PERMIT BOND
KNOW ALL BY THESE PRESENTS, That we,
Minneapolis
(City)
Xcel EnerJn', Inc. d/b/a Northern States Power
as Principal, of 414 Nicollet Mall, 4th Floor
(Street and Number)
and the Liberty Mutual Insurance Company
Minnesota
(State)
, a
Massachusetts
corporation, as Surety, are held and firmly
bound unto City of Prior Lake
Prior Lake, MN , as Obligee, in the sum of
Fifteen Thousand Six Hundred Twenty Five And 00/100 Dollars ($ 15,625.00 )
for which sum, well and truly to be paid, we bind ourselves, our heirs, executors, administrators, successors and assigns, jointly
and severally, firmly by these presents.
Sealed with our seals, and dated this
18th
day of
October
2007
THE CONDITION OF THIS OBLIGATION IS SUCH, That WHEREAS, the Principal has been or is about to be granted
a license or permit to do business as Excavation & Gradin~ per Section 706 of the City Code at the Credit
River Substation at 5930 Credit River Rd., Prior Lake, MN
by the Obligee.
NOW, THEREFORE, if the Principal well and truly comply with applicable local ordinances, and conduct business in
conformity therewith, then this obligation to be void; otherwise to remain in full force and effect.
PROVIDED, HOWEVER:
1. This bond shall continue in force:
D Until , or until the date of expiration of any Continuation Certificate executed by
the Surety
OR
~ Until canceled as herein provided.
2. This bond is effective this 18th day of October 2007 and may be canceled by the Surety by
the sending of notice in writing to the Obligee, stating when, not less than thirty days thereafter, liability hereunder shall
terminate as to subsequent acts or omissions of the Principal.
THIS POV/ER OF ATTORNEY IS NOT VALID UNLESS IT IS PRINTED ON RED BACKGROUND.
"'his Power of Attorney limits the acts of those named herein, and. they have no authority to bind the Company except in the manner and to
the extent herein stated.
2136393
LIBERTY MUTUAL INSURANCE COMPANY
BOSTON,MASSACHUSETTS
POWER OF ATTORNEY
KNOW ALL PERSONS BY THESE PRESENTS: That Liberty Mutual Insurance Company (the .Company.), a Massachusetts stock Insurance
company, pursuant to and by authority of the By-law and Authorization hereinafter set forth, does hereby name, constitute and appoint
TIMOTHY J. WICKER, SUSAN M. VAN PROOYEN, ALLOFTHE CITY OF MINNEAPOLIS, STATE OF MINNESOTA..........
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IN WITNESS WHEREOF, this Power of Attorney has been subscribed by an authorized officer or official of the Company and the corporate seal of ~g
Liberty Mutual Insurance Company has been affixed thereto in Plymouth Meeting, Pennsylvania this 7th day of Mav , = 0
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By the following Instrument the chairman or the president has authorized the officer or other official named therein to appoint attorneys-In-fact:
Pursuant to Article XIII, Section 5 of the By-Laws, Garnet W. Elliott, Assistant Secretary of Liberty Mutual Insurance Company, Is hereby
authorized to appoint such attorneys-in-fact as may be necessary to act In behalf of the Company to make, execute, seal, acknowledge and
deliver as surety any and all undertakings, bonds, recognizances and other surety obligations.
LIBERTY MUTUAL INSURANCE COMPANY
By~4 6/. ~.
Garnet W. Elliott, Assistant Secretary
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I, the undersigned, Assistan retarY()fQtie'rty Mutual tl'is4i'l;lI1ce ComPanY,d()herebyc~l:tify thatttleOriglnal pow!#o(attorney of which the foregoing
is a full, true and correct copy, is in fOllJ~m:eand effect ontl:]~{!~teof t~is.cer:tificate; aMldo furtl1e(~Elrtifyt/:lat~Cifficer or official who executed the
said power of attorney is an AssistaritSec:retary specially atlth9rJz@t>ylfjechairman 6rthe presictetittoaPP9intattomeys-ln-fact as provided In Article
XIII, Section 5 of the By-laws of LibertyMutuallnsurance Company:u '.. . . ." .
CERTIFICATE
This certificate and the above power of attorney may be signed by facsimile or mechanically reproduced signatures under and by authority of the
following vote of the board of directors of Liberty Mutual Insurance Company at a meeting duly called and held on the 12th day of March, 1980.
VOTED that the facsimile or mechanically reproduced signature of any assistant secretary of the company, wherever appearing upon a
certified copy of any power of attorney issued by the company in connection with surety bonds, shall be valid and bindlng upon the company
with the same force and effect as though manually affixed.
IN TOSTI~NY WHEREOF 2~e hereunto subscribed my name and affixed the corporate seal of the said company, this
ctocr , . ~
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~~~i By
t'k~::.l:><!)y ,
'~ Da. . M. CWay, ...~ac,""",
18th
day of
ACKNOWLEDGMENT BY SURETY
STATE OF MINNESOTA
County of HENNEPIN
} ss.
On this 18th day of October
appeared SUSAN M. VAN PROOYEN
Liberty Mutual Insurance Company
2007 , before me personally
, known to, me to be the Attorney-in-Fact of
, the corporation
that executed the within instrument, and acknowledged to me that such corporation executed the same.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal, at my office in the aforesaid County, the day and
year in this certificate first above written.
Nota ublic in the State of
County of HENNEPIN
(Seal)
S-0230/GEEF 10/99
(I)
"EXHIBIT A"
EXCAVATING AND GRADING PERMIT
FOR CITY USE ONLY
PERMIT #
DATE
I 07 t!? - I 0 I
10 I z$/o7
APPlicant:~ ~~X A~..,,- ~R\~ V?~~ Phone#-'-Ici- 33D-60~8
Project/Development Name if APp~cable: {" ~~ Rl~ S()b~tu.I\ E'lr''''~)ol\
Address: 9f3o ~A\L~tJf~ 0
.
Location of Property:
Legal Description:
%~w- ~~~j( MI~~'f'i'II7. MAl
Contractor: ---.i!e' h\~~y
Address: 5l\tM(' 'l5o qb,v(>_
Consultant Engineer/Surveyor: y(~r lYtt.~
Address: 5~*1r itS 9~~
Emergency Contact (24 hr): fl.@3; ~)t~S - ~-N+
'~O ~t ~,,"4
Property Owner:
Address: ~
Phone # -6j.J - S50 ,l6~
Phone #
~"1tW f(.<., ~ k
Phone #
.5'\~~ 't> G..~M..
Phone #
Gl~-31O ~G01b
6\d. -~O~. 0543 cel\
Will the excavation or filling be in a: Watercourse~ Wetland V\() Upland
Purpose for the proposed ~~fyating or filling: i:r.pt~'tn./\ cl eXkj~ ~~
Estimated start date: -----U+1(Q7 Completion date: ~
[What is the type of material to be removed or deposited?
')~ ~ \. What is the quantity of material to be removed or deposited?
\~~ What is the total area disturbed for excavation or filling?
fT\' - In what manner will the material be removed and/or deposited?
What highway, street or other public-way will material for removal or deposition be hauled or carried?
What, if any, street, avenue, lane, alley, highway, right-of-way, thoroughfare or public ground will be obstructed?
y~>
I
IT SHALL BE THE RESPONSIBILITY AND THE BURDEN OF THE APPLICANT TO DEMONSTRATE TO THE SATISFACTION
OF THE CITY ENGINEER FOR THE CITY OF PRIOR LAKE THAT THE PROPOSED EXCAVATION AND/OR FILLING
COMPLIES WITH THE OVERALL CITY OF PRIOR LAKE STORM WATER MANAGEMENT PLAN. SAID BURDEN SHALL
INCLUDE THE FURNISHING OF A REPORT WITH SUPPORTING CALCULATIONS OF A REGISTERED PROFESSIONAL
ENGINEER.
Will proposed excavation or deposition affect the City of Prior Lake overall storm water management plan? Yes_&-
If yes, explain proposed effect
SUBMISSION REQUIREMENTS:
(A) Completed application form
(B) Map or plat of the proposed filling or excavating showing location and amount of material proposed to be removed or
deposited, with a description of the area
(C) The depth or heights to which such removal or deposition is proposed throughout the area and the proposed angle of
all slopes to be shown on a 2' contour map at a scale of 1"=50' or larger. The proposed and original contours shall be
G:lAdminlPW Design Manual\2007 PWDM UPDATE\EXHIBIT A APPLICATION FOR EXCA V & FILLING,doc
1
"EXHIBIT A"
shown including all property within 200' of proposed excavation or deposition and shall be signed by an engineer or
surveyor registered in the State of Minnesota
(D) Erosion control plan
(E) Affect on existing utilities
(F) Application fee
(G) Amount of Letter of Credit, or deposit of monies in a sum sufficient to pay the cost of restoring a site. The extra
ordinary costs of repairing, highways, streets or other public ways along designated routes of travel and to pay such
expenses as the City may incur by reason of doing anything required to be done
(H) Public liability insurance
CONDITIONS OF APPROVAL:
(1) Applicant must call the Engineering Department for erosion control inspection at (952)447-9830 prior to earth moving
activities.
(2) Maximum 4:1 slopes are allowed in "maintained" areas except approved by City Engineer. Maximum 3:1 slopes are
allowed adjacent natural resources.
(3) Slopes greater than or equal to 3: 1 shall have approved erosion control Best Management Practices installed
immediately after finished grading.
(4) Minimum grade for drainage swales shall be 2% or greater.
(5) Removal or depositing of material greater than 400 cubic yards requires a conditional use permit, unless it is part of a
preliminary plat application.
(6) Applicant is responsible for obtaining and meeting the conditions outlined by other permitting agencies including but not
limited to the following: DNR, Corps of Engineer, Prior Lake/Spring Lake Watershed District, Scott County, MN/DOT,
MPCA.
(7) Applicant is responsible for all damages to other property or facilities as a result of work covered by this permit.
(8) Applicant must call the Engineering Department for final grading inspection at (952)447-9830 prior to release of grading
security.
(9) Additional Conditions:
FOR CITY USE ONLY
Date
~~l ~l. Yl~\ -c~y
THE UNDERSIGNED HEREIN CE IFY THAT THEY HAVE READ SECTION 706 OF THE CITY CODE AND ACCEPT THE
TERMS AND CONDITIONS TO T ISSUANCE OF THIS PERMIT AND AGREE TO FULLY COMPLY THEREWITH TO THE
SATISFACTION OF THE CITY 0 P.RIOR KE ENGINEERING DEPARTMENT OR ITS DESIGNATED AGEN . I
Applicant: Date /0 ~ 0
(dl
Property Owner:
AUTHORIZATION OF PERMIT
,. r",' ')5. .N
Financial Guarantee Amount $ _:) _ \c:OII_
Permit Fee $ ,-/~.a5 .
Liability Insurance provided? ~esD No (Insurance Certificate must name the City of Prior Lake as an additional insured party)
Financial Guarantee Type
~~ or Cash)
In consideration of agreement to comply in all respects with the regulations of the City of Prior Lake covering such operations,
and pursuant to authorization duly given by said City of Prior Lake, permission is hereby granted for the work to be done as
described in the above application and submitted drawings, said work to be done in accordance with this application and
submitted drawings.
Permit Expiration Date
Permit is valid if signed by City Official
Date I t;). I '2S I \:if
ENGINEERING OFFICIAL
o~
Planning Dept. Initia~
'-"
G:\AdminIPW Design Manual\2007 PWDM UPDATEIEXlllBIT A APPLICATION FOR EXCA V & Fll.LING,doc
2
Attachment to Excavating and Grading Permit for Xcel Energy
Credit River Substation - City of Prior Lake
What is the type/quantity of material to be removed or deposited?
1800 CY of topsoil to be removed
450 CY of fill to be deposited
620 CY of base material to be deposited
150 CY of crushed rock to be deposited
500 CY of topsoil top be deposited
What is the total area disturbed for excavation or filling?
28,314 square feet or .65 acres total
In what manner will the material be removed and/or deposited?
With the use of backhoes, loaders, dump trucks, etc.
What highway, street or other public-way will material for removal or deposition be
hauled or carried.
Credit River Road and Eagle Creek Avenue.
What street, avenue, lane, alley, highway, right-of-way, thoroughfare or public
ground will be obstructed?
None
Credit River Substation
PID # 259010260
The East 250 feet of the following described property:
That part of the East % of the SE 'l4 of Section 1, Township 114, Range 22,
Described as follows: Commencing at the SE corner of said section 1;
thence on an assumed bearing ofN 01021 '00" W along the line between the
SE corner and the NE corner of said section 1, a distance of 1251.72 feet;
thence at right angles S 88039' W, a distance of 1875.73 feet; thence S
86011 '30" W, a distance of 84.66 feet to the east line of the west 30.0 feet of
the East % of the SE 'l4 of said Section 1; thence N 86011' 30" E, a distance
of 514.66 feet; thence bearing south a distance of 704.31 feet to the
centerline of County State Aid Highway #12; thence S 63037'56" E along
the centerline of said Highway #12 a distance of73.66 feet to the ACTUAL
POINT OF BEGINNING of the property to be described; thence bearing
North a distance of 412.0 feet; thence bearing East a distance of944.0 ft;
thence bearing South a distance of 870 ft, more or less, to the centerline eof
County State Aid Highway #12; thence NW'ly along the centerline of said
Highway #12 a distance of 1053, more or less to the point of beginning.
Subject to County State Aid Highway #12 over the SW'ly 33 feet thereof.
Said East 250 shall be measured along the North line of the aforedescribed
property .
Except,
The North 380 feet.
PHONE NO. 612-333-3323
FAX NO.
612-373-7270
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURER A: ACE American Insurance Company
INSURER B:
Hays Companies
IDS Center, Suite 700
80 South 8'" Street
Minneapolis, MN 55402
INSURED
Xcel Energy Inc.
Northern States Power Company
Public Service Company of CO
Southwestern Public Service Co
414 Nicollet Mall 4'" Floor
Minneapolis MN 55401
INSURER C:
INSURER 0:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING
ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TOWHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
"OR ADOL TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR INORD DATE IMMIDDlYY) DATE (MM/DDNY)
~ENERAL LIABILITY EACH OCCURRENCE $2,000,000
DAMAGE TO RENTED
A X X COMMERCIAL GENERAL LIABILITY HDOG2371727A 11101/07 11/01/08 PREMISES (Ea oCC<llTellCej $2,000,000
I-- b CLAIMS MADE [R] OCCUR
f-- MED EXP (Anyone person) $10,000
f-- PERSONAL & ADV INJURY $2,000,000
GENERAL AGGREGATE $20,000,000
f-- PRODUCTS-COMP/OP AGG $2,000,000
nN'L AGGREGA LIMIT APPLlnER:
POLICY PROJECT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $2,000,000
A X ANY AUTO ISAH08234826 11/01107 11/01/08 (Ea Accident)
-'-'-
ALL OWNED AUTOS BODILY INJURY
- (per Person)
SCHEDULED AUTOS
'x HIRED AUTOS BODILY INJURY
I-- (Per Accident)
~ NON-OWNED AUTOS
f-- PROPERTY DAMAGE
(per Accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT
R ANY AUTO OTHER THAN EA ACC
AUTO ONLY: AGG
OCESSlUMBRELLA LIABILITY EACH OCCURRENCE
OCCUR D CLAIMS MADE AGGREGATE
R DEDUCTIBLE
RETENTION
I WcSTATlJ. I Ton+
WORKERS COMPENSATION AND X TORY LIMITS ER
A EMPLOYERS' LIABILITY WLRC43141995 lAOS) 11/01/07 11/01/08 EL EACH ACCIDENT $2,000,000
A ANY PROPRIETOR/PARTNER/EXECUTIVE SCFC43141983 (WI) 11/01/07 11/01/08 E,L DISEACE - EA EMPLOYEE $2,000,000
OFFICERlMEMBER EXCLUDED?
If yes, describe under EL DISEASE - POLICY LIMIT $2,000,000
SPECIAL PROVISION BELOW
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Regarding: Permitto excavate and grade at the Credit River Substation, 5930 Credit River Road, Prior Lake, MN 55372. City of Prior lake is included as additional insured as
respects General Liability as required by written contract.
CERTIFICATE HOLDER I I ADDITIONAL INSURED; INSURER lETTER: CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~DAYS
City of Prior Lake WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO TIlE LEFT, BUT FAILURE TO
Engineering Department DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS
4646 Dakota Street SE AGENTS OR REPRESENTATIVES,
Prior Lake, MN 55372 AUTHORIZED SIGNATURE
~'.~
ACORD 25 (2001/08)
@ ACORD CORPORATION 1988
Ross Bintner
From:
Sent:
To:
Subject:
Rogers, Christopher C [Christopher.C.Rogers@xcelenergy.com]
Monday, October 22, 2007 9:56 AM
Ross Bintner
Credit River Substation
Hi Ross,
Here is the breakdown of erosion control costs for the substation expansion as we
discussed on Friday. Please let me know if there is anything else needed in order
for us to obtain the excavating and grading permit.
Silt fencing
Seeding
Maintenance, repairs
Total:
$3500.
$8000.
$1000.
$12,500.
Thanks,
Chris Rogers
Xcel Energy
Siting and Land Rights Agent
ph: 612-330-6078
fax 612-573-1861
1
ACORo.
PRODUCER
PHONE NO. 61 2-333-3323
FAX NO.
612-373-7270
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
OOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURER A: ACE American Insurance Company
INSURER B:
Hays Companies
IDS Center, Suite 700
80 South 8'" Street
Minneapolis, MN 55402
INSURED
Xcel Energy Inc.
Northern States Power Company
Public Service Company of CO
Southwestern Public Service Co
414 Nicollet Mall 4'" Floor
Minneapolis MN 55401
INSURER C:
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSR ADD!. TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR IHIlAD DATE (MMlDDlYY) DATE (MMIDDlYY)
~NERAL LIABILITY EACH OCCURRENCE $2,000,000
A X X COMMERCIAL GENERAL LIABILITY HDOG2371937 A 11/01/06 11/01/07 DAMAGE TO RENTED $2,000,000
- ~ CLAIMS MADE PREMISES (Eo OCCUrTence)
- [K] OCCUR MED EXP (Anyone person) $10,000
PERSONAL & ADV INJURY $2,000,000
-
- GENERAL AGGREGATE $20,000,000
~N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COM PlOP AGG $2,000,000
POLICY n PROJECT n Lac
~TOMOBILE LIABILITY COMBINED SINGLE LIMIT $2,000,000
A X ANY AUTO ISAH08221728 11/01/06 11/01/07 (Ea Accident)
-'-'-
- ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (per Person)
-
~ HIRED AUTOS BODILY INJURY
~ NON.oWNED AUTOS (per Accident)
- PROPERTY DAMAGE
(per Accident)
~RAGE LIABILITY AUTO ONLY - EA ACCIDENT
ANY AUTO OTHER THAN EA ACC
AUTO ONLY: AGG
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE
tJ OCCUR D CLAIMS MADE AGGREGATE
R DEDUCTIBLE
RETENTION
, I WCSTATlJ. I 1 OTK-
WORKERS COMPENSATION AND X TORY LIMITS ER
A EMPLOYERS' LIABILITY WLRC44442577 (AOS) 11/01/06 11/01/07 EL EACH ACCIDENT $2,000,000
A ANY PROPRIETOR/PARTNER/EXECUTIVE SCFC44442565 (WI) 11/01/06 11/01/07 E.L DISEACE - EA EMPLOYEE $2,000,000
OFFICERlMEMBER EXCLUDED?
~ yes, describe under E.L DISEASE - POLICY LIMIT $2,000,000
SPECIAL PROVISION BELOW
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Regarding: Permilto excavate and grade at the Credit River Substation, 5930 Credit River Road, Prior Lake, MN 55372. City of Prior Lake is included as additional insured as
respects General liability as required by written contract.
CERTIFICATE HOLDER I I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
City of Prior Lake EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 2Q..DAYS
WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO
Engineering Department DO so SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER. ITS
4646 Dakota Street SE AGENTS OR REPRESENTATIVES,
Prior Lake, MN 55372 AUTHORIZED SIGNATURE
~i4--
ACORD 25 (2001/08)
@ ACORD CORPORATION 1988