HomeMy WebLinkAboutExcavating & Filling Permit - #10-G-09 �
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'"'"n�°'"` "EXHIBIT A"
FOR CI7Y USE ONLY
EXCAVATING AND GRADING PERMIT PERMIT # ---p
DATE - p
� Applicant: eS �sC� �' `� � M�' i� Phone # /SZ - 86 8- g�o 16
ProjecUDevelopment Name if Applicable: /.�2�Z�'fZ�Z��
Address: S� SU (�, /33 �� 5 7� SC� v Q c_ 2
Property Owner: Gre 6 5�� Phone #/S2-
Address: /' � %
Contractor: �a r''�-'� C�.S ��UV 'C Phone #
Address:
Consultant Engineer/Surveyor: Phone #
Address:
Emergency Contact (24 hr): V'�� Q �¢SR � �( Phone #�S 2 ° z 9Z - Z07 ✓
Location of Property: SS�p OV���CY�I� /�r'. T//�Y' KQ
Legal Description:
Will the excavation or filling be in a: Watercourse Wetland Upland '
Purpose for the proposed excavating or filling: bUi/ D v� S�� � 62.�i/i/�c.✓ � QLJ r'P�ii1i�/! ���
Estimated start date: C� Completion date: /S
What is the type of mate al o 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?
In what manner will the material be removed and/or deposited? U �
What highway, street or other public-way will material for removal or dep sition be hauled or carried? C� c'
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 C1TY OF PR10R 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 REG2UIREMENTS:
(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 propos@d and original contours shall be
G:\Admin\PW Design Manua1�2007 PWDM UPDA1'E\EXHIBII' A APPLICATION FOR EXCAV & FILLING.doc
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�^^�°"'` "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,
M PCA.
(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 O CI Y OF PRIOR LAKE ENGINEERING DEPARTMENT OR ITS DESIGNATED AGE T.
Applicant: Date
`� Z 8 r�o/o
Property ner: Date
FOR CITY USE ONLY
AUTHORIZATION OF PERMIT
Financial Guarantee Amount $ S� �DD �inancial �uarantee Type (Letter of Credit, Bond, or Cash)
Permit Fee $ /1�A.�t�
Liability Insurance provided? 0 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 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.
ENGINEERING OFFICIAL ,_, ,� ----- Date ���7"'�D
Permit is vatid if signed by Ciry Official
Permit Expiration Date �` ��v Planning Dept. Initials DP
G:Wdmin�PW Design Manua1�20U7 PWDM UPDATbIEXHBIT A APPLICATION FOR EXCAV & FILLING.doc
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ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYI�
08/26/2010
PRODUCER Phone: 763-551-T300 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Affiliated Insurance Services LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
� HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
12805 Highway 55 Suite 212 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Plymouth, MN 55441
INSURERS AFFORDING COVERAGE NAIC #
INSURED ir,suReRn: WEST BEND MUTUAL
Designscape Plus LLC �NSUReR s: West Bend Mutuai
5350 W 133RD ST INSURER C:
SAVAGE, MN 55378 INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR 7HE POLICY P O D. NOTWITHSTANDING
ANY REQUIREMENT. TERM OR CONDITfON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH T C AAY BE ISSUEp OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUS DITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSRADD' pOLICYNUMBER POLICYEFFECTIVE POLICYEXPIRATION �
A GENERAL LIA8ILITY BC00999635 05/15/2010 05/15/2011 EACH OCCURRENCE � 1 000 000 .
X COMMERCIAL GENERAL LIABILITY PREM�SES� a occurence � � OO OOO
CLAIMS MADE � OCCUR MED EXP (Any one erson S 5 ���
PERSONAL & ADV INJURY $'I OOO OOO
GENERAL AGGREGATE S Z OOO OOO
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2 OOO OOO .
X POLICY PR � LOC
B AUTOMOBILE LIABILITY BC00999635 05/15/2010 05/15/2011 COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $ 1 000 000
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS
BODILY INJURY $
NON-OWNED AUTOS (Per accfdent)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: pGG S
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR � CLAIMS MADE AGGREGATE $
$
DEDUCTIBLE S
RETENTION $ $
WORKERS COMPENSATION AND WC STATU- OTH-
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTNE E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYE $
If yes, describe under
SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOlDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCECLED qEFORE THE EXPIRATION
City of Prior Lake DATE THEREOF, TH@ ISSUING INSURER WILI ENDEAVOR TO MAII �O DAYS WRITTEN
ATTN .JUCI�/ NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 30 SHALL
4646 Dakota Street SE ��pOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Prior Lake, MN 55372 REPRESENTATNES.
AUTHORRED REPRESENTATNE
DSM
ACORD 25 (2001/08) O ACORD CORPORATION 1988
Printed by DSM on August 26, 2010 at 10:25AM
IMPORTANT
If the certifi�`I�iolder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this c i�ate d�es not confer rights to the certificate holder in lieu of such endorsement(s).
� �G�I N IS WAIVED sub'ect to the terms and conditions of the olic , certain olicies ma
f' 1 P Y p Y
I� @R�. A statement on this certificate does not confer rights to the certificate
��� de ' lieu of such endorsement(s).
��
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, e�end or alter the coverage afforded by the policies listed thereon.
ACORD 25 (2007/08)
Printed by DSM on August 26, 2010 at 10:25AM
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