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HomeMy WebLinkAboutExcavating & Filling Permit - 08-G05 4 a "EXHIBIT A" FOR CITY USE ONLY EXCAVATING AND GRADING PERMIT PERMIT # )J1' DATE Applicant \ `( Q"Iryr l 03 CA. N■i\ Phone# 6 6 - l - g 33 C- Project/Development Name if Applicable: NA Address: \LQ -1 c ?G� i eoc'. CSC • Property Owner SO \\ 5 . C \C1 .'S � Phone # l,/. 1? '36 / 02 u Address I Q ' j \n l'..)Ckol elk ab- 1 C� t. 5• W L U -tom, 95'2- Contractor: AJ P r t —/r(k) C� 1 � f .TC. ,�1 2 Phone # `7y r u v Address Q O yc �� 1 'Qh i Gl / 1 i to 553 Consultant Engineer /Surveyor: —!V Al ' Phone # Address. Q-�6/57 ` 9 Emergency Contact (24 hr): \■•' ,. h '� Q�9r Phone # -/ �' 4� - /✓ 2 3 Location of Property: V..65 (13006L 3lat'V\ C 5k/ Legal Description: Will the excavation or filling be in a: Watercourse Wetland Upland Purpose for the proposed excavati or filling: ( ` Q (.s'r u JoX\ r 6simI SC' ' tom) Estimated start date: J! )' Q Completion date: if J' What is the type of material to be removed or deposited? (hi gC. « \l bf SC K 011.71- What is the quantity of material to be removed or deposited? %.41" - 0j What is the total area disturbed for excavation or filling? 1'S1) Sc 110v-a') In what manner will the material be removed and /or deposited? 5 r,! (Oc, c - What highway, street or other public -way will material for removal or deposition be hauled or carried? \41 1)Gt.Gt� 4 12.t 4 C. f' What, if any, street, avenue, lane, alley, highway, right -of -way, thoroughfare or public ground will be obstructed (+� 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 No 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 \Adorn \PW Destgn Manual \2007 PWDM UPDATE EXHIBIT A APPLICATION FOR EXCAV & FILLING doc 1 � Ylttn "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: THE UNDERSIGNED HEREIN CERTIFY THAT THEY HAVE READ SECTION 706 OF THE CITY CODE AND ACCEPT THE TERMS AND CONDITIONS TO THE ISSUANCE OF THIS PERMIT AND AGREE TO FULLY COMPLY THEREWITH TO THE SATISFACTION OF THE C OF PRIO: v.. ENGINEERING DEPARTMENT OR ITS DESIGNATED AGENT. r /d' _ ^a r Q l Applicant: ` — Date i Property •wner: Date FOR CITY USE ONLY AUTHORIZATION OF PERMIT �I , Financial Guarantee Amount $ Financial Guarantee Type ✓ LY (Letter of Credit, Bond, or Cash) Permit Fee $ 23 S C Liability Insurance provided? Yes❑ No (Insurance Certificate must name the City of Prior Lake as an additional insured party) In consideration of agreement to comply in all respects with the regulations of the City of Prior Lake covenng 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 1� ENGINEERING OFFICIAL Date .� 5 C Permit is valid if signed by City Official Permit Expiration Date /SC I - C'S Planning Dept. Initials ' G Admin \PIA Design Manual\2007 PWDM UPDATE \EXHIBIT A APPLICATION FOR EXCAV & FILLING doe 2 -----Jul. 22. 2008_ 2:04PM No. 2329_P. 1/1 ACORLZ CERTIFICATE OF LIABILITY INSURANCE DATE Whoa) _ PRODUCER (952) 831 -1928 FAX (952)831 -0572 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Advance Insurance Agency, Inc, ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 5241 Vi ki n Drive Ste 200 HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 8 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Edina, MN 55435 . INSURERS AFFORDING COVERAGE NAIC 11 INSURED Krueger Excavating INSURER& Allied Insurance — 00035 DIM; Nate Krueger INSURER B: 7577 175th St E INSURER C.; Prior Lake, MN 55372 INSURER 0: INSURER E: _OVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEBABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH 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 LIMIT$ SHAWN MAY HAVE BEEN REDUCED 8Y PAID CLAIMS. DM ADM POIJCY EFFECnVE POLICY EXPIRATION NSRr. TYPE OF INSURANCE POLICY NUMBER OA , I AMITIO YY)_DgTF IM DMYI uMiTS GENERAL LIABILITY ACP 7102418338 11/15/2007 11/15/2008 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE T O R€NT E� „rw) $ 100 000 I CLANS MADE © OCCUR MED EXP (Any one person) S 1,000 A PERSONAL $ AOV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEM AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGO $ 2,000,000 — I POLICY n 128, n LOC - AUTOMOBILE LIABILITY ACP 71024183 38 11/15/2007 11/15/2008 COMBINED SINGLE LRAT X ARTAUTO (Eaaocideni) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY $ I A _ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Peracddeni) PROPERTY DAMAGE (Par accident) GARAGE LIABILITY moo ONLY EAACCIDENT $ ANY AUTO EA ACC S OTHER THAN _ t r AUTO ONLY AGG S EXCESSIUMBRELLA UAeIL TY ACP 7102418338 11/15/2007 11/15/2008 EACH OCCURRENCE $ 2,000,000 OCCUR n CLAIMS MADE AGGREGATE $ 2,000,000 A g DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND I WC STJ?4 I I rnav 1 IMI EMPLOYERS' UABIUTY EL. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFIOERIMEMBEREXCLUDED? E.L DISEASE - EAEMPLOYEE $ II de1p{119 uAa SREGIAL PROVISIONS below _ E.L. DISEASE - POLICY LIMIT S OTHER DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES 1 ExCLUSIQNS ADDED OY ENDORSEMENT /SPECIAL PROVrsioNs CERTIFICATE HOLDER CANCELLATION SHOULD AMY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFGRB THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL City of Prior Lake DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Nate BUT FAILURE YO MAIL SUCH NOME SHALL IMPOSE NO OBLIGATION OR LIABILITY 4646 Dakota Street SE OF ANY KIND UPON THE INSURER, 116 AGENTS OR REPRESENTATIVES. Prior Lake, MN 55437 AUTHORIZED REPRESENTATIVE Mark Aitchi ACORD 26 (2001108) FAX: (952)447 -4263 @ACORD CORPORATION 1988