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HomeMy WebLinkAboutBuilding Permit 10.0515 r i i 9 r t , , a� �„ ` v + ' i__. ., i , i iir. _. .ir: ,irYf f ay _ ..I1 :rr' fi � i r,.i _ YY ,� Yi .iY r . ' ..iY' , _. iY ,. ,,., i „ ti , _ , r.:�i. _: I 1 . ii .c C nrrfifttafr of (®tnprxni r ' � CITY OF PRIOR LAKE ' Pry ttft;� of ix���xt g jInsprtfiou ---: ›, Final Permitted ❑ Conditional C.O. Expires . > Thi Certificate issued pursuant to the requirements of Section 110 of the ❑ R / O In Building Code certifying that at the time of issuance this structure was in compliance with the various • , ordinances of the City of Prior Lake regulating building construction or use. For the following: x Use Classification ,. ; N C v ( y ∎ ,�) c r” GQ 1' ^ �l L Bldg Per No ?, Occupancy Type R Type Construction V Zoning District l ? 1 :: . k b r Legal Description ! °\ e -e" ' ,„. r , Sri �( Owner of Building k<, i^ v ` Gc Y \ \ + - '' `'t Site Address (0 e.) 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Pink City 3 Yellow Applicant (Please type or print and sign at bottom) ADDRESS ZONING (office use) vo V Vo VL S'\ \\),t_ 2 / SL) LEGAL DESCRIPTION (office use only) LOT BLOCK ADDITION PID 2S, 935 O / Z- . d (Name) \ i y'+' ck' 1 i\ 1 f\-e 9'4,\I t viA (Phone) — 410- b i 6 Q (Address) \S3 q ‘ lQ,OI A)R4 ikk s S .E.. S'I a k ( (Company ) \ n (Phone) h C _., Com an Name �+ Pa r 6 3 Phone �D1 °� " Co Z r� (Contact Name) 0 \ 11 Pa 4 2..\ N M' ' \ _ {y� (Phone) C \' '— `O� G- sn a N (Address) a3 rn a R ,,,\,\A V44 ) t% 1_CA 1\ \h, S SO IA Li TYPE OF WORK 'AI New Construction ['Deck []Porch DRe- Roofing ❑Re- Siding ❑Lower Level Finish ❑ Fireplace DAddition ❑Alteration EUtility Connection CODE: R.C. DI.B.C. 1:3 Misc. 00 Type of Cbnst action: I II III IV V AB PROJECT COST /VALUE $ ) l (IC) Occupancy Group: A B E F HI MR S U Division: 1 2 3 4 5 (excluding land) 1 hereby certify that I have furnished information on this application which is to the best of my knowledge true and correct. I also certify that I am the owner or authorized agent for the above - mentioned property and that all construction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building o ' . an revoke this permit for ju : hereby a gree that the city of ficial or a designee may enter upon the property to perform needed inspections. - 4■15 cl a1 aoio Signature Contractor's License No. Date Permit Valuation 4 .300 Park Support Fee # $ Permit Fee $ 7 / 00 Gc " SAC # $ Plan Check Fee $ �/ ¢ Water Meter Size 5/8 "; 1 "; $ 4737 0 0 State Surcharge , ' $ 6z-0,00 Pressure Reducer $ /2:5", 00 Penalty $ Sewer /Water Connection Fee # $ Plumbing Permit Fee $ ` /'� ` Water Tower Fee # $ Mechanical Permit Fee $ � n1 � Builder's Deposit $ /3 O 0.00 C/ /'n l Sewer & Water Permit Fee $ 52-, CJ Qt'�ee - - E tL - P ,% `r r $ S Gas Fireplace Permit Fee $ L -0, 02_) 1 TOTAL DUE / $ /4 4// (0 ' This Ap do r t ecomes Your Building Permit + en Ap roved Paid /� 4-- (� �p • : Ceipt No. Q p (p Ap � �4 Date (o . /S, / U ► '� ' B 4 uilding fficial Date This is to certify that the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requested. This document when signed by th ity Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy must be issued. C—/SAD /l1., r ,'t�r e restie►vt .0/�Ierna� • anning Director Date Special Conditions, if 24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 4646 Dakota Street Prior Lake, MN 55372 c:s PR/ 04, CITY OF PRIOR LAKE Date Rec'd U 45- DEMOLITION PERMIT rN1V E SOS f/ (iG- (lo -.516 . . . PERMIT NO.O? 7 (Please type or print and sign at bottom) ADDRESS ZONING (office use) 4 tG % S \--CI AA6 &C , V..0 i f r resit LEGAL DESCRIPTION (office use only) . LOT BLOCK ADDITION PID OWNER ` D (Name) 1ilrL 1�Lth f� �s\�� l�\ � (Phon � "1 „" -Q 1 (Address) % a\ ikt 5 i.) _, S r'..., '? 6 n r tik,\-t; CONTRACTOR nn (Company Name) 1-ka . h i\ N IN b r�ch (Phone) \ tZ " Ea 6 v I` n Q\ (Contact Name) Co Pi y rlV E. L\ It N (Phone) C ‘ .--- ca 1 t" S14 kA (Address) a - 14 - 1Q.-,, , t,W p\A tik Use of Building: INTERNATIONAL BUILDING CODE Type of Construction: I II III IV ® A 5 /NG.v z. E h4M /4. y DGVEti--/1✓!. Occupancy Group: A B E F H I M R S U Division: 1 2 3 4 5 "MPCA NOTIFICATION OF INTENT TO PERFORM A DEMOLITION I hereby certify that I have furnished information on this application which is to the best of my knowledge true and correct. I also certify that I am the owner or authorized agent for the above - mentioned property and that all construction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building official can revoke this permit for just cause. Furthermore, ereby ree that thee& fficial or a designee may enter upon the property to perform needed inspections. • Signature Date METRO (MCES) SAC UNIT This Application Becomes Your Demolition DETERMINATION I P-rm%' When .Approved 2) 650,95 �oDO. - LAS G/e..)c.J iv 1/".., ... L / , . � , i' ,, fZ . �® Building 0 ' cia Date This is to certify that the - quest in the abov- .. 'cation and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requested. /"- /47 — 3 - ®9 Pl. • Rirector Date Special Conditions, daily 24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 16200 Eagle Creek Avenue, Prior Lake, Minnesota 55372 o f PR/ CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd A. TEMPORARY CERTIFICATE OF ZONING COMPLIANCE /3 ! 0 x AND UTILITY CONNECTION PERMIT ` �ln'NES01P I. White File pERMIT NO . 704 3 Penk Cp / O 3 Yellow Applicant (Please type or print and sign at bottom) ADDRESS ZONING (office use) 4/6813 Loos- sr A /.• E , LEGAL DESCRIPTION (office use only) LOT BLOCK ADDITION PID 11 • 0 OWNER It, (Name) (Phone) (Address) , ph - Pools akdtY1-wi . G6rr% BUILDER tr‘ti (Compan y Name) e / 0� s (Phone 4 S 7 . Via / 391 (Contact Name) i'ti ( I) 6./ L• 7.s 12. is' (Address) 3 .. L t ri E e A 1 J= .,i�Z. 5 SI 1 TYPE OF WORK ❑ New Construction ['Deck ['Porch DRe-Roofing ❑Re- Siding ❑Lower Level Finish ❑ Fireplace ❑Addition ❑Alteration ❑Utility Connection Miss. 5V I r'1t1) N Po OL CODE: (LR.C. ❑LB.C.i 9 Type of Construction: I II III IV V A B PROJECT COST /VALUE $ ca2570410 Occupancy Group: A B E F HI MR S U Division: 1 2 3 4 5 (excluding land) 1 hereby certify that 1 have furnished information on this application which is to the best of my knowledge true and correct. I also certify that I am the owner or authorized agent for the above- mentioned property and th constru i will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building official can revoke this pe/fiuYcausermore , I hereby agree that the city official or a designee may enter upon the property to perform needed n inspect s. X ,A'.r //a Signature Contractor's License No. Date Permit Valuation Park Support Fee # $ Permit Fee $ /& 2 C" SAC # $ Plan Check Fee $ Water Meter Size 5/8 "; 1 "; $ State Surcharge $ S 0 0 Pressure Reducer $ Penalty $ Sewer /Water Connection Fee # $ Plumbing Permit Fee $ Water Tower Fee # $ Mechanical Permit Fee $ 54-, Builder's Deposit $ Sewer & Water Permit Fee $ Other $ Gas Fireplace Permit Fee $ TOTAL DUE t. , n Al u-x. I o ,' Li $ Z 2 /. 75 This t at Becomes Your Building Permit Whe Ap oved Paid 7/1- � C ^eipt No. (p // i�� Date 70 ,(ii. cd i! Building 11" 41..__...._... ate This is to certify that the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requested. This document when signed by the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy must be issued. P ning Director Date Special Conditions, if any 24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 4646 Dakota Street Prior Lake, MN 55372 Residential Building Permit Checklist New Construction for Single or Two - family Dwellings in R-1 or R -2 Districts Reviewed by: 5,..cf mit Date: - / �p Building Permit # PID: as-_ 93s __ 01,77 _ 0 Zoning: 4 9_ /3D Address: 116 Lards -t- Legal: L • , B Subdivision: • Existing Nonconforming MM., Existing Structure? YES Q> g 9 Structure? YES CONFORMS TO ZONING C NO ORDINANCE Yard Setbacks: NA I FAILS/ COMPLIES Standard I Proposed • Front Yard (can be 20' if avg. wrn 150') 25' a s I ' • Side Yards 101 25' if abutting a street • Sidewall exceeding 50' requires additional side 2" 10' setback + . setback for every 1' over 50' in length 271' over 50' • Rear Yard 25' NA • Patio Door provide for minimum 10' deck or sign 10' side/ //A statement indicating no deck will be built in the future 25' rear • From 100 year flood elevation of wetland /NURP 30' NA pond • From OHW (Prior or Spring Lake) 75' or setback average of 5o, it ' adjacent structures, but no Tess than 50' I Floor Area Ratio: NA 1 FAILS 1 COMPLIES 1 .30 Maximum I 0 . 0 7 I Yard Encroachments: NA / FAILS /COMPLIES Standard Proposed 1 Eaves and Gutters no more than 2 feet in width and no closer than 5 feet to a lot line (Easements). NC and other equipment cannot encroach on interior `ti side yards. Tree Preservation: NA / FAILS 1 COMPLIES 1 Standard I Proposed • Total caliper inches 3 is " • Permit25% Removal /05 • Caliper Inches Removed a 76 • Caliper Inches Preserved • Replacement W1 83.-5 "or a `Itrees 0 Y eocl•' L: \TEMPLATE\BLDGLIST.DOC Driveway: NA/ FAILS 1 COMPLIES Standard I Proposed • Maximum width at property line 24' /3' yi,,, • Required setback 5' from side lot line or 0' ,ir 30' from r -o-w on comer lots /4 • Maximum slope 10% • All parking areas to be paved including R -V or spaces adjacent to the garage ""`P l ;es • Location to match subdivision grading plan / I Building Height: NA / FAILS 1 COMPLIES 35' Maximum 1 Shoreland District: NA / FAILS / COMPLIES Standard 1 Proposed r Minimum lot area (square feet) 7,500 Rip, 7,999 Non -rip r... / 0 /°e Minimum lot width 50' Rip, 57.3° Non -rip ca. `A -s Shoreland alterations Impervious surface 30% Maximum c9.2. 6 7. Bluff in Shoreland: NA / FAILS / COMPLIES Standard Proposed • Setback from top of bluff By planning dept. NA • Bluff impact zone 20' From Top of Bluff /v A • Engineering certification submitted /approved By City Engineer /4 • Grading in bluff or bluff impact zone No importing/exporting /V ff Floodplain: NA / FAILS / COMPLIES Standard I Proposed r .. • 100 year flood elevation C" 908.9' Prior Lake T44' $pn; g Lake /2 • Lowest floor elevation X909.9' Prior. Lake 1 q ®9 915.4' Spring Lake • Proposed lowest floor elevation Must be 1' above flood elevation for new and existing structures. If existing structure was constructed 9/19/90- 11/22/97 then additional foot is not required. • Elevations 15 feet from structure Must be flood elevation or higher 9 ®S, 9 • Road access must be no more than 2 feet below 907.9' for Prior Lake Regulatory Flood Protection Elevation 913.4' for Spring Lake Accessory Structure: NA / FAILS 1 COMPLIES Standard II Proposed • Size 832 sq.ft. or 25% rear yard g S • Not located in front yard (Materials) • Side yard and rear yard setbacks 10' • Maximum height 15' • Materials compatible with principle structure L : \TEMPLATE\BLDGLIST.DOC f in/ b E PC ! n j WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 8 0 4 7 4 WELL AND BORING SEALING RECORD Minnesota o Unique Well No. Minnesota Statutes, Chapter 103/ or W - series No. Township Nagle Township No. Range No, Section No. Fraction (sm. -+ lg.) Date Sealed Date Well or Boring Constructed s t r) r t,I4., 115N w 3_ N E'4114rv e , -// 3/ oci (,.-, K GPS Latitude degrees minutes seconds Depth Before Sealing 13 0 ft, Original Depth c/l.. X tt. LOCATION: Longitude degrees,_ minutes__ seconds AOUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑ Multiaquifer J / ' J ��. A F. '' / � V ELL/BORING V Measured ❑ Estimated Date Measured 7 16 n I r `I'���'f f�,t' ( Water- Supply Well Q Monit. Well Show exact location of well or Sketch map of well or boring in section grid with "X:' /�- 3- , p 111�ation, showing property U Env. Bore Hole ❑ Other_ 9 ft below ❑ above land surface N •ies, roads, and buildings. CASING TYPE(S) 111111111111111 \Steel Q Plastic L] Tile ❑ Other __ W IN E WELLHEAD COMPLETION ���E T \ i Outside: ❑ Well House ❑ At Grade Inside: ❑ Basement Offset �E�� Mile 7 I \ Pitless Adapter /Unit ❑ Buried ❑ Well Pit I .2 El S ❑ Well Pit 1 — I �.. s.1 Q Other ❑Other 1 Mile 1V OPERTY OWNER'S "E/COMPANY N'�, E CASING(S) Cr.•J ■ 4 4 f 1 ./t'a (A x.46 Diem! Depth Set in oversize hole? Annular space initially grouted? Property owner's mailing address if differ than well location address indicated a ove ,y in. from 0 _ to 7 ft. ❑ Yes NNo ❑ Yes 0 No 1S,Unknown —/ in, iron 7 to J 2 L ft. ❑ Yes I5,no ❑ Yes ❑ No INinknown ____ in, from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN � `} Well owner's mailing address i1 different than property owner's address indicated above Screen from % KY to �:::) R. Open Hole from _ to ft. OBSTRUCTIONS NkRods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction Type of Obstructions (Describe) ..... — GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? \Yes ❑ No Describe_ -- PUMP I • G \ 1 If not known, indicate estimated formation log from nearby well or boring. 4 Dr Type / w , k ,d w t^ f7 p 4+ r ' � r n _e, _ /z4 Removed ` Not Present ❑ Other ___ Jl IGi - .....S. `2L, )30 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE: A No Annular Space Exists ❑ Annular Space Grouted with Tremie Pipe Q Casing Pedoration/Removal in. from _ to ft. ❑ Perforated ❑ Removed __ in. from _ to h. ❑ Perforated [; Removed Type of Perforator ❑ Other - GROUTING MATERIAL(S) (One bag L of cement = 94 lbs., one bag of bentonite = 50 lbs.) Grouting MaterialN�4r / �rr'd r- from Q to dS0 tt. yards ) bags ` from to ft. yards bags from to, _ k. yards bags OTHER WELLS AND BORINGS REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes 'lo How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was seated in accordance with Minnesota Rules, Chapter 4725. The information contained in this report is true to the best of my knowledge. • . )yy5 Licensee Busin me License or Registration No. A, 4.:0 Certified Representative Signature Certified Rep. No Date MINN. DEPT OF HEALTH COPY H 280474 444 - -- - -- - - -- -- Name of Perso eating Well or Boring --'ham HE- 01434 -11 ICa 140 -0423 ��� yowl (FRIP U trf White - Building "'�NrvESO�P Canary - Engineering Pink - Planning BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT ' /�% / � - 7-6) APPLICATION RECEIVED . /3. . / The Building, Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: 4-4 g (6 Accepted X Accepted With Corrections Denied Reviewed By: 321 C Date: q/23//0 Comments: See Attachments: 1) Grading Plan, 2) Erosion Control Measures See Reverse Side for Additional Information! "The issuance or granting of a permit or approval of plans, specifications and computations shall not be construed to be a permit for, or an approval of, any violation of any of the provisions of this code or of any other ordinance of the jurisdiction. Permits presuming to give authority to violate or cancel the provisions of this code or other ordinances of the jurisdiction shall not be valid." ADDITIONAL COMMENTS FOR BUILDING PERMIT APPLICATIONS, • Surface storm water drainage flowing to the perimeter of this lot to and from adjoining properties must be conveyed to the roadway and /or to the rear of the lot in drainage swales within the drainage easement. • All bare soil areas must be protected from eroding into neighboring properties through the properly installed and maintained silt fence or bales. • The silt fence required by the erosion control plan must be installed prior to any earthwork being started. • The builder is responsible for maintaining the erosion control measures until the turf is established. • The rock construction entrance must be installed at the time of backfilling of the foundation. GAAdmin \dept info \AbbITIONAL COMMENTS FOR BUILDING PERMIT APPLICATIONS,doc z r !, ..,, _ > ... , • T'A. , . - - .: �s^S6g. . ., , w°: -r - ; ?�.ar�.� =" �'`°�s�.r l�,� O� PRip�, v rrt White - Building �INNESa�P Canary - Engineering Pink - Planning BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT fri/et l :f / U APPLICATION RECEIVED / ' . ie The Building, Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: 4-& L. 'ice %,i / iL c = I Accepted Accepted With Corrections Denied Reviewed By: sy Date: 7-023—/p Comments: "The issuance or granting of a permit or approval of plans, specifications and computations shall not be construed to be a permit for, or an approval of, any violation of any of the provisions of this code or of any other ordinance of the jurisdiction. Permits presuming to give authority to violate or cancel the provisions of this code or other ordinances of the jurisdiction shall not be valid." O� PRio4 U tr1 White - Building Canary - Engineering 'yINNEsdc'' Pink - Planning BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT f i 6 577'E Pco LS APPLICATION RECEIVED . /3. 10 The Building, Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: 4(0,9E, toe -5 Accepted Accepted With Corrections Denied • Reviewed By: / •L,,_ Date: 9 2/ to Comments: (. RE&.' ( (44" c, E1 C41•- - f. 41A 779- Cc-Spli•-) '7 2.667 Art A (1.-1 c,..1.4 se"-- 0.)G. L_AT_ c_44. i ►.! U &/A--r& Il cl4 1- I k-357 --� . 0 4 no P ASS i Li 5p -- rca ' 6 -- j���nXa PCO . cv II-A- E4 4 - r • ■r - c-. hi M tJ f i. "R 26 v 5 or P o L 5 PR -o\/t06 2 . ©�. coo- I ®lL Fex) qtr '' P 116 , A coN -r' J LTA fd a n 5C42v&jj2 Sr tr c 17 ES r EL) &E eq F- P ®o LeV.41i. // Is As ✓E' lot.? I t- LevA"rlvv &c-rote Poem PR- Sri "The issuance or granting of a permit or approval of plans, specifications and computations shall not be construed to be a permit for, or an approval of, any violation of any of the provisions of this code or of any other ordinance of the jurisdiction. Permits presuming to give authority to violate or cancel the provisions of this code or other ordinances of the jurisdiction shall not be valid." a Y S—.c, C I 01 ,0 I\ . , t I 1 I t v i rf ti b N. I �1( / I 4 F4-n-A, c s G v n.0 ,V t e¢ 4 r f PR/0 U try White - Building MNNES��P Canary - Engineering Pink - Planning BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT /W EL f 7fNN `oti 6 S APPLICATION RECEIVED S- a /0 The Building, Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: 46 8'0 Loma Accepted Accepted With Corrections '/ Denied Reviewed By: Date: 5/Z s /io Comments: (• 61- 05 /JA Cc. /v 5" �,�rS 4r AA, Ti^?� Z . A c ,r L91-1 F $ 2v'6 04. SsA -ri•ve. TH- r- TlfLow€5 Fr - 6-t-e✓A (S 49 ✓6 9 cf .ei ELE-444r(d„I 774 /cc p /NsALec-r PASs 3. 4 FC074 1 Is •-ce /4 7 otc- a :c -4v is /ss 4 . .4 �IsveD L — �� M c r (s "The issuance or granting of a permit or approval of plans, specifications and computations shall not be construed to be a permit for, or an approval of, any violation of any of the provisions of this code or of any other ordinance of the jurisdiction. Permits presuming to give authority to violate or cancel the provisions of this code or other ordinances of the jurisdiction shall not be valid." 0 PRIo> ti e u z _ 1 White - Building P Canary - Engineering �INNES °� Pink - Planning BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT A,./.., L. t ` / t ir : f ,/ /-7L,/,, � . APPLICATION RECEIVED my The Building, Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: Accepted Accepted With Corrections Denied Reviewed By: �-- Date: (- /S /e Comments: / M4 14,0 Is re p r,. ,4_ t Teo. 6/ y oJtu r Cer . iea, 11/11As Ze. eolpleted l er/ r to 73uncia301■ / 6 ap�vr ®Yd / 1 OerwVt - re G at'rea( Pfr■r /loci( tuft“ea". fine Ka .J /'hfiteh4vt Insist 6e it nf: a�zriw, err poo %ef- v Tee repia.ccrrrx.t reeurrei % /g A' •:17 / ,teenier Zees Te ,' j 0 ' ', , r(r.c� i '- nPh an6 N "The issuance or granting of a permit or approval of ;.plans, specifications and computations shall not be construed to be a permit for, or aft ::approval of, any violation of any of the provisions of this code or of any other ordinance -t4 the jurisdiction. Permits presuming to give authority to violate or cancel the p ns of this code or other ordinances of the jurisdiction shall not be valid." PRIp � y ti 'y ' White - Building � NNESOfcP Canary - Engineering Pink - Planning BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT 1 ` -.' ' i-1 P / A / L'. -7 el APPLICATION RECEIVED 5 . / / / 0 The Building, Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: Accepted Accepted With Corrections Denied Reviewed By: y'-.-. Date: 3. / /(' Comments: See Attachments: 1) GradingP,an, 2) Erosion Control Measures 1 See Reverse Side for Additional Information! "The issuance or granting of a permit or approval of plans, specifications and computations shall not be construed to be a permit for, or an approval of, any violation' of any of the provisions of this code or of any other ordinance of the jurisdiction. Permits presuming to give authority to violate or cancel the provisions of this code or other ordinances of the jurisdiction shall not be valid." O P RIO Date Rec'd H CITY OF PRIOR LAKE 73 g SEWER AND WATER PERMIT 4f jA'NESo 'c . 1 G reYellow Cit en File PERMIT NO. � n 575 2 . 3. G Applicant (Please type or print and sign at bottom) ADDRESS 4-6 e G � �� mss , 71 L / t ZONING (office use) LEGAL DESCRIPTION (office use only) LOT BLOCK ADDITION PID OWNER .K.:1„,.. A T oc2 ti . 6 0\ (Phone) (Asa- 11119_ l a w (Address) (Address) (City) (Zip Code) APPLICANT -3" 3c,7.0 (Name) J. /L Srt,v 8 74 c, .j' (Phone) 6)�/- `/6 /G /9 (Address) / 9 7 S' 2 13 ST G,/ . Pet 4- AA / ;v Vv31 44 Al 5 y (Address) (City) (Zip Code) (Contact. Person) . A IC, A 5"9 v e._ ., t (Phone) 6 rI - /6 7 c/a APPLICANT SIGNATURE 1 (/� ,,,-1 DATE - 2 — — /0 APPLICANT PLEASE COMPLETE BELOW Size of water service / inches. Location of any couplings from structure feet. Type of sewer pipe. ❑ ABC E. PVC ❑ Cast Iron Estimated length of sewer line feet. Clean out (if required) located at feet from structure. FEE SCHEDULE Residential sewer and water line connection $51.50 Industrial, Com'l & Multi- family 1% of job cost with a $51.50 minimum Sewer connection only $25.50 Water connection only $25.50 Estimated Cost $ Building Permit # SEWER AND WATER PERMIT FEE $ PAID WITH STATE SURCHARGE $ *BUILDING PERMIT TOTAL PERMIT FEE $ • (Office Use Only) This , t 6 tar Becomes Your Building Permit W en / proved Paid Receipt No. By _ �(� �� Date B t me Officia ate 24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 4646 Dakota Street S.E., Prior Lake, Minnesota 55372 . !). ;;A,Nr. • 04 rxxo CITY OF PRIOR LAKE Date Rec'd • HEATING /AIR CONDITIONING /FIREPLACE PERMIT 4 tIlvnEsoo 2. t. i tm: T y PERMIT NO. io , 56 3. Yllow App &a (Please type or print and sign at bottom) ADDRESS f ZONING (office use) V688 L01rr, (3/ N. ifi'or n LEGAL DESCRIPTION (office use only) . LOT BLOCK ADDITION PID (Name) M i Fl G r f� e. //i (' (' I (Phone) (Address) yb $b' t / r(S Ow_ /V • E 9 ,f inr LR 4, V1'11� / • APPLICANT t (Name) �� Y (Ur) �1n , - Inc . (Phone) 661 "( K // i.3 (Address) y 11 6-506 Address `Z< � L2/1 R( -(I l VU Y7')1 U R-e:ri IA )/ 6 - 5066 - • ddress) (City) (Zip Code) (Contact Person) -- L' /. , / tZ � 1 (OJ 'c3 (Phone) S ` ' '1 APPLICANT SIGNATURE AilI ' /_ DATE /Q " APPLICANT PLEASE COMPLETE BELOW (3INEW CONSTRUCTION 0 REPLACEMENT ❑ ALTERATIONS FURNACE MAKE AND MODEL -71 MPP - O(,(, -ct o — !109( ?( "L FUEL '.i FLUE SIZE 3 t RETURN OPENINGS /1 INPUT q A OUTPUT l lL I.. • TYPE OF SYSTEM . HEATING. OR POWER PLANT PLEASE NOTE: Air Conditioner ❑Warm Air Plants 0 Steam Units and Fireplaces Cannot Encroach DGravity ' • ❑ Hot Water into Required Side Yard Setbacks. , ® Mechanical 0 Radiation Fireplaces with Box Additions or Air Conditioning ❑Special Devices Cantilevers to the Outside of Buildings Vent. System N Other Devices tit Require a Building Permit. FIREPLACE MAKE AND MODEL FEE SCHEDULE • Industrial, Conunercial & Multi- Family l% of job cost Residential, Gas. Fireplace $49.50 • 1 minimum Residential, Heating & A/C (New Construction) 9.5 t Residential, Additions & Alterations 849.50 Residential, Heating Only (New Construction) 864.50 Residential, AC Only p� $49.50 Estimated Cost $ Building permit # PAID WITH BUILDING PERMIT HEATING PERMIT FEE $ STATE SURCHARGE $ .50 _ TOTAL PERMIT FEE $ (Office Use Only) This Application Becomes Your Building Permit When Approved Paid Receipt No. Date By , Buildtne Official Date _ 24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 4646 Dakota Street S.E., Prior Lake, Minnesota 55372 P DEPARTMENT OF R'OR L BUILDING AND INSPECTION INSPECTION RECORD SITE ADDRESS 44.86 L 02-o5 r 14. E. NATURE OF WORK s'fsv FA"+�� D��e��l,�c9 (MC.. DEEKA: L.L Fl,4, No Ftwar.,1 USE OF BUILDING 5 F +> PERMIT NO. /p -40.5t,,5" DATE ISSUED 6/5/0 CONTRACTOR AD EL MAN N I - 1oo mE5 PHONE SZ 7-4 NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW THE PERMIT IS BY SEPARATE DOCUNX k , IE 11 L ,r, es INSTpe..` �Z-m . �r.� �,. 01AIN ' i ►' t!N �- � ^ _ INSPECTOR DATE FOOTING �,as Wc. I /' ✓ G• I to 1 FOUNDATION (Prior to Backfill) r "F: tee°; 4 a ,,��,;, a ,, e PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED R4 °' sisr' ' —' - ROUh - INS SEWER/WATER/SEPTIC Scc fP FRAMING , ii n o., b pe i / 1 4 INSULATION r 2.v.1 Cl«y f;0 /fer /44.4. ELECTRICAL PLUMBING ,j HEATING (if required) if FIREPLACE (ic') tt2ts' Q f GAS LINE AIR TEST 1/24`q k P I twc-• St'er _ COVER NO WORK UNTIL ABOVE HAS BEEN SIGNTD 4 1 (-16.->s<- -A-rt4c 1 1 FINALS GRADING (Prior to Sodding) BUILDING Fr PIA orir. v kik // 30 // ELECTRICAL PLUMBING HEATING P/3 /2.ah DO NOT OCCUPY UNTIL ABOVE HAS BEEN SIGNED NOTICE This card must be posted near an electrical service cabinet prior to rough -in inspections and maintained until all inspections have been approved. On buildings and additions where no service cabinet is available, card shall be placed near main entrance. FOR ALL INSPECTIONS (952) 447 -9850 Land Surveyors Planners • Valley Surveying Co. P (952) 447 -2570 Suite 230 16670 Franklin Trail S.E. Prior Lake, Minnesota 55372 June 28th, 2410 , �_ Slb Kim Pellicci 15341 Red Oaks Road SE Prior Lake, MN 55372 RE: 4688 Lords Street CERTIFICATION: I hereby certify that on June 28th, 2010, I did measure the top of the poured foundation at the walkout level of the house under construction at 4688 Lords Street, Prior Lake, Minnesota. I further certify that the elevation of said walkout level wall is 910.7 NGVD'29. mo w. Scott M. Swanson, PLS Minnesota License Number 42309 Our file No.10655 - • . . . . . . - - U.& DEPARTMENT OF HOMELAND SECURITY . ELEVATION CERTIFICATE . I :OMB No 1680-0008. . I Federal Emergency Management Agency . 1 -;-- ... -- • . . . Expires February 28. 2009 National Flood Insurance Program . • .. Important : Read the instructions on pages 1-8. • . - . • • • • - - • . •• • . • • • - • ..* ' ' - ' . . SECTION A - PROPERTY INFORMATION , For insWencis Company Use:. • . Al. Building Owner's Name - - . . PolicyNumber . • - • '.. /5 i e - ti..' i - : ' - • . • . • " . . . A2, Eldletg Street Address (Including•Apt., Unit, Suite, and/or Bldg. No.) Or P.O. Route and Box No.. . . CoMpany NAIC Number • • . 4■0 6Z Log- 0.5. .51 1 . • - . City -0 . . r RAI IC- . /-0-441- • . • '• . . • State • , % • ' - /vi ry • ZIP Code . A3. Property Description (Lot and Block Numbers, Tax Pircel Number, Legal Description, etc.) - • ' - • . .. . . , . . • • . . . A4. Budding Use (e. ., Resider Addition, Accessory, etc.) - —_____ - . - A5. Latitude/Longitud . . . . ' ' Long - • Horizontal Datum: 0 NAD 1927 U NAD 1983. . A6. Attach at least 2 photograiihs of the bukding if the CertMcate is being used to obtain flood insurance. . - - A7. Building Diagrain Number . ' - • - . .- - . . - . .A8... For a buldkIg with 'a crawl space or Einclosure(s), provide: • - - . ' * A9. For a buiding with an attached garage, provide: . - - • . • • a) Squwe footage crawl apace or endosUre(s) . - . . sq ft . ' a) Sways footage of attached garage - . $q ft . b) Na of permanent flood openings in the MAW space ar - - - • b) No. of permanent flood openings In the attached gage enclosure(s) walls within 10 foot above a4acent grade • - wails.wklin 1.0 foot above adjacent grade c) - Total net area of flood openings in Atl.b • , : • WI In c)- Thiel net wee of flood openings In Aftb . • sq in . . . ' - '• ' . . - '-' • • SECTION B -FLOOD INSURANCE RATE MAP (RRM) INFORMATION . " . . . 81. NFIP Communky Name & Community Number ' - 82. County. Name , 83. State . . . . . * . . . . • . B4. Map/Panel Number . - B& Suffix - ".86. FIRM index • B7. FIRM Newt • 88. Flood 89.*Base.Flood Elevation(s) (Zone . . : Date :•- . ' Effective/Revised Date . .Zone(s) . ' AO, use base flood depth) . . . . C i t 0 9 . . . . • ' • . . • . 810. Indicate the source of the Base Flood.Elevation (BFE) data or base flood depth entered In Item 89.. . . . , - • 0 FIS Profile . 0 FIRM Reawnunity Determined . 0 Other (Describe) B11. Indicate elevationdahmi used for EWE in kern 88: 0 NOVO 11r29 .. 0 NAVO 1988 rn i.i Other (Describe) • ' ' B12.. Is the building totaled in a Coastal Barrier Rtasotutet System (CB 8) area dr Oth�rwtse Protected Area (OPA)7 0 Yes r No • • Designation Date ' CBRS 0 OPA ' . . • • - - - SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) . - C1. Building elevations are based on: 0 Construction Drawings* . aBuliding Under Construction' 0 Finished Construction * A new Elevation Certificate wki berequired when construction of the building is complete. . . C2. Elevations - Zones A1 AE, AH, A (with BFE), VE, V1-V30, V (with BFE), AR, ARIA, AR/AE, AR/A1-A30, AR/AH, AR(AO. Complete Items C7..a-g - below according to the building diagram specillertkt item A7. ' . , .. . . . Benchinalt Ut6zed . - - • .. - - . - Vertical Datum • NGVD ' adj. . .. . • . - Conversion/Commena • . : • • - • . ' . • . .. . . . . . . . . . Check the measurement used. • . . . . . • . . . . . . a) • of bottom floor (includin9 basement, crawl sluice, or endosure floor) 9 10 • - . 7 g feet ' 0 meters (Puerto Rico only) - -. . b) • Top of the next higher. floor ' . - - • • - : -. - - • . . - . _ . _ U feet, U meteri(Puerto Rico only) - • . c)- -. - Bottorn•of the lowest horizontal structural member (V Zones only) .. •.• 0 feet 0 meters (Puerto Rico only) • - ' . • . • d) Attached garage (top of slab) - - .' : . - ' - • • . 0 feet - 0 meters (Puerto Rico only) e) Lowest elevation of machinery or equipment servicing the building - . , 0 feet 0 meters (Puerto Rico alb') . . • (Describe type of equipment In Comments) f) . Lowest adjacent (finished) grade (LA(3) . . • - _ - ._ 0 feet . meters (Puerto Rico only) • -: g) . Highest adjacent (finished) grade (I-1 . - . , . . . ._CI feet meters (Puerto Rio only) • . . • - . SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION . . • - This certMcWion Is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to cerWy elevation . . . • • - - information. I certify that the infommtion on this Cartncate mptesents my beat efforts to kitelpret the data available. . . I understand that any false statement may be punishable by Ane or imprisonrnerd under 18 U.S. Code . , Section 1001. . . . . . , . 0 CheCk-here if cOmmenti are provided On of back fomi. ., . _ -- - . ., . • • . . . - r-va, • ............... - • Codifies Name • ..- • - " . . . . Lkense Number - • - . • - . • ......... . . Scout••,M. Swanson • -' . - - • - 42309 • - , :prrtr:. • . Tkle • - - Company Nene - 'Land .Surveyor ' • . - - • . Valley Surveying Co., P.A. . State NN . ZIP Code 55372 - 5372 - - • • . - l 'rankilln 'Trl . • . S . E .• .. CitY Prior ' Lake . - Signattu _,.....2- j_ ...._ ,.. ....., .-• , Date • / - , Telephone - - - • • (952) 447-2570 . - • .. • . • FEMAForm 81-31, February 2006 - - - • ' See reverse side for continuatkm. . - • _Replaces all previous editions IMPORTANT: In these spaces, copy the corresponding Information from Section A For tnswance Company Use: Building Street Address (inducing Apt, Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. Policy Number • 'fv SS 1.4., le p •S' � �2�'f ,— • City Z 7 �� /G � state �� J CompanyNAIC Numb& SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) Copy both sides of this Elevation Certificate for (1) community official, (2) Insurance agent/company, and (3) building owner. • can„rwir't �,� Cr e L ckse 6.-7 I y - /?/ �� / 7 v /r�.,�ic h Signature Date 67Z a . 0 Check here if attachments SECT fON E - BUILDI LEVATION INFORMATION SURVEY NOT REQUIRED) FOR ZONE AO ( ) ZO A AND ZONE A (WITHOUT BFE) For Zones AO and A (without BFE), complete items E1 -E5. If the CertHk;ate is Intended to support a LOMA or LOMR -F request, complete Sections A, B, and C. For Items E1-E4, use natural grade, if available. Check the measurement used. In Puerto Rico only, enter meters. Et Provide elevation information for the fchlawfng and check the appropriate boxes to show whether the elevation is above or below the highest adjacent grade (HAG) and the lowest adjacent grade (LAG). a) Tcp of bottom floor (induding basement, pawl space, or endoswe) is ❑ feet ❑ meters ❑ above or ❑ below the HAG. b) Top of bottom floor (tndudng basement, crawl space, or enclosure) is ❑ feet ❑ meters ❑ above or. ❑ below the LAG. E2. Far Building Diagrams 6-8 with permanent flood openings provided in Secti9p4 Items 8 War 9 (see Rage 8 of Instructions), the next higher floor (elevation C2.b in the diagrams) of the building is _ ❑ feet LJ meters U above or u below the HAG. E3. Attached garage (top of stab) is 0 feet 0 meters 0 above or ❑ below the HAG. E4. Top of platform of machinery and/or equipment servkdng the bung is i ❑ feet ❑ metes ❑ above or ❑ below the HAG. E5. Zone AO only: If no flood depth number Is evadable, Is the top of the bottom floor elevated in accordance with the community's muniy's floodplain management ordinance? ❑ Yes ❑ No ❑ Unknown. The local official must certify th s information In Section G. SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION The property owner or owners authorized representative who completes Sections A, B, and E for Zone A (without a FEMA- issued or community-Issued BFE) or Zone AO must sign here. The statements In Sections A, 5, and E are correct to the best of my knowledge. Property Owner's or Owners Authorized Representative's Name Address City State ZIP Code Signature Date Telephone Comments SECTION G - COMMUNITY INFORMATION (OPTIONAL) The local official who is authorized by law or ordinance to administer the community's floodplain manegerient ordinance can complete Sections A, 8, C (or E), and G of this Elevation Certificate. Complete the applicable item(s) and sign below. Check the measurement used in Items 08. and G9. 31. ❑ The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor, engineer, or architect who Is authorized by law to certify elevation information. (Indicate the source and date of tine elevation data in the Comments area below.) G2. 0 A community official completed Section E for a buidkng located In Zone A (without a FEMA- Issued or communly -Issued BFE) or Zone AO. 03. ❑ The foNowhng Information (Items G4. -G9.) Is provided for community floodplain management proposes. G4. Permit Number G5. Date Permit Issued G6. Date Certificate Of Compliance/Occupancy Issued G7. This permit has been Issued for 0 New Construction 0 Substantial Im%rovement G8. Elevation of ass -built lowest floor (inducing basement) of the budding: ❑ feet ❑ meters (PR) Datum • G9. BFE or (In Zone AO) depth of flooding at the bufd ing site: ❑ feet ❑ meters (PR) Datum Load Official's Name Title Community Name Telephone • Signature Date • Comments ❑ Check here if attachments j=EMA Form 81 - 31, February 2006 oe.,�...,,... "II ITCO ALLIED ENGINEERING CO. AN ALLIANCE OF INSTANT TESTING COMPANY AND ALLIED TEST DRILLING Jobsite and Laboratory Testing, Geotechnical Services, Commercial, Residential and Municipal 7125 West 126th Street, Suite #500 - Savage, MN 55378 Telephone (952) 890 -7386 Fax (952) 890 -5883 SOIL INSPECTION REPORT Adelmann Homes PO Box 564 LI--<51 Lakeville, MN 55044 Pro' • • • • s • • • e Prior Lake Date Sa • =: = Reported: 6 -21 -2010 Ordered By: Customer Performed By: Ken Schaaf This report is in regard to the inspection and testing done at 4688 Lords Street in Prior Lake. The footing forms had been set up prior to the inspection and soil was sampled from between them near the northwest corner. This turned out to be a dark sandy loam with some organic material present. The amount of organic was minimal though and as soil was quite stable in this area, it was judged good enough to remain. All the soils in the perimeter footings were quite solid and stable but when tested with a dynamic cone penetrometer it was discovered that the single footing line in the center was on some quite unstable with soft layer below the surface having a bearing load capacity of below 1,500 pounds per square foot. This area was at 4.5 feet above the perimeter and the contractor agreed to remove all the unsuitable soils and build the wall higher in this area. No other correction was deemed necessary. Dynamic Cone Penetrometer Tests Test Number: 1 2 Location: 4' x 4' pad 12' W of center 3' W of E end of center footing footing Depth Below Grade: 1' 5' Soil Classification: Sandy clay loam DCP Depth Millimeters /Inches: 715mm / 28.1" 501 mm / 19.7" Per Blow Average /Millimeters: 34 28 N- Value: N -9 N -11 Estimated Load pounds Per Square Foot: 3,200 3,700 Spec Required: Assumed 2,500 PSF Charge Codes: Mobilization #701 1 DCP Tests #601 1.75 Charge Per Test #304 2 Mileage #612 14 Signed: -- Gordon J. Kopacek, Professional Engineer — Registration No. 7254 1.4 $,6 LaeOS 37 er /0 - 5/5 U.S. DEPARTMENT OF HOMELAND SECURITY - FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. NO. 1660 - 0015 PROPERTY INFORMATION FORM Expires December 31, 2010 PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this form is estimated to average 1.63 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to respond to this collection of information unless a valid OMB control number appears in the upper right comer of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, U.S. Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington DC 20472, Paperwork Reduction Project (1660 - 0015). Submission of the form is required to obtain or retain benefits under the National Flood Insurance Program. Please do not send your completed survey to the above address. This form may be completed by the property owner, property owner's agent, licensed land surveyor, or registered professional engineer to support a request for a Letter of Map Amendment (LOMA), Conditional Letter of Map Amendment (CLOMA), Letter of Map Revision Based on Fill (LOMR -F), or Conditional Letter of Map Revision Based on Fill (CLOMR -F) for existing or proposed, single or multiple lots/structures. In order to process your request, all information on this form must be completed in its entirety. Incomplete submissions may result in processing delays. Please check the item below that describes your request: ® LOMA A letter from DHS -FEMA stating that an existing structure or parcel of land that has not been elevated by fill (natural grade) would not be inundated by the base food. ❑ CLOMA A letter from DHS -FEMA stating that a proposed structure that is not to be elevated by fill (natural grade) would not be inundated by the base flood if built as proposed. ❑ LOMR -F A letter from DHS -FEMA stating that an existing structure or parcel of land that has been elevated by fill would not be inundated by the base flood. A letter from DHS -FEMA stating that a parcel of land or proposed structure that will be elevated by ❑ CLOMR-F fill would not be inundated by the base flood if fill is placed on the parcel as proposed or the structure is built as proposed. Fill is defined as material from any source (including the subject property) placed that raises the ground to or above the Base Flood Elevation (BFE). The common construction practice of removing unsuitable existing material (topsoil) and badfilling with select structural material is not considered the placement of fill if the practice does not alter the existing (natural grade) elevation, which is at or above the BFE. Fill that is placed before the date of the first National Flood Insurance Program (NFIP) map showing the area in a Special Flood Hazard Area (SFHA) is considered natural grade. Has fill been placed on your property to raise ground that was previously below the BFE? ❑ Yes ® No If yes, when was fill placed? / month/year Will fill be placed on your property to raise ground that is below the BFE? ❑ Yes No If yes, when will fill be placed? 1 month/year 1. Street Address of the Property (if request is for multiple structures, please attach additional sheet): 4688 Lords Street, Prior Lake, MN 55372 2. Legal description of Property (Lot, Block, Subdivision)(complete description as it appears in the Deed is not necessary): P/o Government Lot 8, 35- 115 -22, Scott County, Minnesota 3. Are you requesting that the SFHA designation be removed from (check one): ❑ the entire legally recorded property? ❑ a portion of land within the bounds of the property? (A certified metes and bounds description and map of the area to be removed, certified by a licensed land surveyor or registered professional engineer, are required. For the preferred format of metes and bounds descriptions, please refer to the MT -1 Form 1 Instructions.) ® structures on the property? What are the dates of construction? 2010 4. Is this request for a (check one): single structure ❑ single lot ❑ multiple structures (How many structures are involved in your request? List the number. ) ❑ multiple lots (How many Tots are involved in your request? List the number. ) DHS - FEMA Form 81-87, DEC 07 Property Information Form MT -1 Form 1 Page 1 of 2 It, • N":". • • In addition to this form (MT -1 Form 1), ALL requests must include the following: • Copy of the effective FIRM panel and/or Flood Boundary and Floodway Map (FBFM) (if applicable) on which the property location has been accurately plotted (property inadvertently located in the NFIP regulatory floodway will require Section B of MT -1 Form 3) • Copy of the Plat Map for the property (with recordation data and stamp of the Recorder's Office) OR • Copy of the property Deed (with recordation data and stamp of the Recorder's Office), accompanied by a tax assessor's map or other certified map showing the surveyed location of the property relative to local streets and watercourses • Form 2 — Elevation Form. If the request is to remove the structure, and an Elevation Certificate has already been completed for this property, it may be submitted in lieu of Form 2. If the request is to remove the entire legally recorded property, or a portion thereof, the lowest lot elevation must be provided on Form 2. Please include a map scale and North arrow on all maps submitted. For LOMR -Fs and CLOMR -Fs, the following must be submitted in addition to the items listed above: • Form 3 — Community Acknowledgment Form Processing Fee (see instructions for appropriate mailing address; or, visit http: / /www. Tema. gov /plan/preventlfhm /frm_fees.shtm for the most current fee schedule) Revised fee schedules are published periodically, but no more than once annually, as noted in the Federal Register. Please note: single/multiple lot(s) /structure(s) LOMAs are fee exempt. The current review and processing fees are listed below. Check the fee that applies to your request: ❑ $325 (single lot/structure LOMR -F following a CLOMR -F) ❑ $425 (single lot/structure LOMR -F) ❑ $500 (single lot/structure CLOMA or CLOMR -F) ❑ $700 (multiple lot/structure LOMR -F following a CLOMR -F, or multiple lot/structure CLOMA) ❑ $800 (multiple lot/structure LOMR -F or CLOMR -F) Please submit the Payment Information Form for remittance of applicable fees. Please make your check or money order payable to: National Flood Insurance Program. All documents submitted in support of this request are correct to the best of my knowledge. I understand that any false statement may be punishable by fine or imprisonment under Title 18 of the United States Code, Section 1001. Applicant's Name: Kim Petlicci Company: Please Print or Type Mailing Address: 4688 Lords Street Daytime Telephone No.: Prior Lake, MN 55372 E -Mail Address: Fax No.: (optional) Date Signature of Applicant (required) If you have any questions conceming DHS -FEMA policy, or the NFIP in general, please contact the FEMA Map Assistance Center toll free at 1-877 - FEMA MAP (1- 877 - 336- 2627), or visit the Flood Hazard Mapping website at http: //www.fema.gov/fhm /. DHS - FEMA Form 81-87, DEC 07 Property Information Form MT -1 Form 1 Page 2 of 2 U.S. DEPARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE OMB No. 1660 -0008 Federal Emergency Management Agency Expires March 31, 2012 National Flood Insurance Program Important: Read the instructions on pages 1 -9. SECTION A - PROPERTY INFORMATION For Insurance Company Use: Al. Building Owner's Name Kim Pellicci Policy Number A2. Building Street Address (including Apt., Unit, Suite, and /or Bldg. No.) or P.O. Route and Box No. Company NAIC Number 4688 Lords Street City Prior Lake State MN ZIP Code 55372 A3. Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.) P/o Government Lot 8, 35- 115 -22, Scott County, Minnesota. (PID#259350120) A4. Building Use (e.g., Residential, Non - Residential, Addition, Accessory, etc.) Residential A5. Latitude /Longitude: Lat. 44.43494 Long. 93.25328 Horizontal Datum: ❑ NAD 1927 ® NAD 1983 A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance. A7. Building Diagram Number 1 A8. For a building with a crawlspace or enclosure(s): A9. For a building with an attached garage: a) Square footage of crawlspace or enclosure(s) 2,005 sq ft a) Square footage of attached garage 945 sq ft b) No. of permanent flood openings in the crawlspace or b) No. of permanent flood openings in the attached garage enclosure(s) within 1.0 foot above adjacent grade 3 within 1.0 foot above adjacent grade 4 c) Total net area of flood openings in A8.b 20.268 sq in c) Total net area of flood openings in A9.b 33.732 sq in d) Engineered flood openings? ❑ Yes 0 No d) Engineered flood openings? ❑ Yes ® No SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION B1. NFIP Community Name & Community Number B2. County Name B3. State Prior Lake, Minnesota 270432 Scott MN B4. Map/Panel Number B5. Suffix B6. FIRM Index B7. FIRM Panel B8. Flood B9, Base Flood Elevation(s) (Zone 270432 0002 C Date Effective /Revised Date Zone(s) AO, use base flood depth) 07/26/74 11/19/97 AE, X500 909.0 B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in Item B9. ❑ FIS Profile ® FIRM ❑ Community Determined ❑ Other (Describe) B11. Indicate elevation datum used for BFE in Item B9: ® NGVD 1929 ❑ NAVD 1988 ❑ Other (Describe) B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? ❑ Yes ® No Designation Date ❑ CBRS ❑ OPA SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) C1. Building elevations are based on: ❑ Construction Drawings* ❑ Building Under Construction* ® Finished Construction *A new Elevation Certificate will be required when construction of the building is complete. C2. Elevations - Zones A1-A30, AE, AH, A (with BFE), VE, V1 -V30, V (with BFE), AR, AR/A, AR/AE, AR/A1 -A30, AR/AH, AR/AO. Complete Items C2.a -h below according to the building diagram specified in Item A7. Use the same datum as the BFE. Benchmark Utilized Vertical Datum NGVD 1929 Conversion /Comments Check the measurement used. a) Top of bottom floor (including basement, crawlspace, or enclosure floor) 910.7 El feet ❑ meters (Puerto Rico only) b) Top of the next higher floor 921.7 0 feet ❑ meters (Puerto Rico only) c) Bottom of the lowest horizontal structural member (V Zones only) ❑ feet ❑ meters (Puerto Rico only) d) Attached garage (top of slab) 920.9 ❑ feet ❑ meters (Puerto Rico only) e) Lowest elevation of machinery or equipment servicing the building ❑ feet ❑ meters (Puerto Rico only) (Describe type of equipment and location in Comments) f) Lowest adjacent (finished) grade next to building (LAG) 909.6 0 feet ❑ meters (Puerto Rico only) g) Highest adjacent (finished) grade next to building (HAG) 920.9 ISI feet ❑ meters (Puerto Rico only) h) Lowest adjacent grade at lowest elevation of deck or stairs, including 910.5 0 feet ❑ meters (Puerto Rico only) structural support SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information. 1 certify that the information on this Certificate represents my best efforts to interpret the data available.1 understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001.0 Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a licensed land surveyor? 0 Yes ❑ No Certifier's Name Scott M. Swanson License Number 42309 Title President Company Name Valley Surveying Co., P.A. Address 16670 Franklin Trail SE City Prior Lake State MN ZIP Code 55372 Signature Date 01/13/11 Telephone 952 -447 -2570 -1 IMPORTANT: In these spaces, copy the corresponding information from Section A. For Insurance Company Use: Building Street Address (including Apt., Unit, Suite, and /or Bldg. No.) or P.O. Route and Box No. Policy Number 4688 Lords Street City Prior Lake State MN ZIP Code 55372 Company NAIC Number SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agent/company, and (3) building owner. Comments The existing structure on the subject property is a full basement walkout. The intemal aspects of this dwelling are still under construction at the date of this certificate. However, per builder, external construction is substantially complete. On the subject property there exists a detached boat house/ shed which has a slab elevation of 904.1. At the time the data was collected, the top of ice elevation of Prior Lake was 902.9. All elevations on NGVD 29 adj. datum. Signa Date 01/13/11 0 Check here if attachments SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT BFE) For Zones AO and A (without BFE), complete Items E1 -E5. If the Certificate is intended to support a LOMA or LOMR -F request, complete Sections A, B, and C. For Items E1 -E4, use natural grade, if available. Check the measurement used. In Puerto Rico only, enter meters. E1. Provide elevation information for the following and check the appropriate boxes to show whether the elevation is above or below the highest adjacent grade (HAG) and the lowest adjacent grade (LAG). a) Top of bottom floor (including basement, crawlspace, or enclosure) is ❑ feet ❑ meters ❑ above or ❑ below the HAG. b) Top of bottom floor (including basement, crawlspace, or enclosure) is ❑ feet ❑ meters ❑ above or ❑ below the LAG. E2. For Building Diagrams 6 -9 with permanent flood openings provided in Section A Items 8 and/or 9 (see pages 8-9 of Instructions), the next higher floor (elevation C2.b in the diagrams) of the building is ❑ feet ❑ meters ❑ above or ❑ below the HAG. E3. Attached garage (top of slab) is ❑ feet ❑ meters ❑ above or ❑ below the HAG. E4. Top of platform of machinery and /or equipment servicing the building is ❑ feet ❑ meters ❑ above or ❑ below the HAG. E5. Zone AO only: If no flood depth number is available, is the top of the bottom floor elevated in accordance with the community's floodplain management ordinance? ❑ Yes ❑ No ❑ Unknown. The local official must certify this information in Section G. SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION The property owner or owner's authorized representative who completes Sections A, B, and E for Zone A (without a FEMA - issued or community- issued BFE) or Zone AO must sign here. The statements in Sections A, B, and E are correct to the best of my knowledge. Property Owner's or Owner's Authorized Representative's Name Address City State ZIP Code Signature Date Telephone Comments ❑ Check here if attachments SECTION G - COMMUNITY INFORMATION (OPTIONAL) The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A, B, C (or E), and G of this Elevation Certificate. Complete the applicable item(s) and sign below. Check the measurement used in Items G8 and G9. G1. ❑ The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor, engineer, or architect who is authorized by law to certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.) G2. ❑ A community official completed Section E for a building located in Zone A (without a FEMA - issued or community- issued BFE) or Zone AO. G3. ❑ The following information (Items G4-G9) is provided for community floodplain management purposes. G4. Permit Number G5. Date Permit Issued G6. Date Certificate Of Compliance/Occupancy Issued G7. This permit has been issued for: ❑ New Construction ❑ Substantial Improvement G8. Elevation of as -built lowest floor (including basement) of the building: ❑ feet ❑ meters (PR) Datum G9. BFE or (in Zone AO) depth of flooding at the building site: ❑ feet ❑ meters (PR) Datum G10. Community's design flood elevation _ ❑ feet ❑ meters (PR) Datum Local Official's Name Title Community Name Telephone Signature Date Comments fl Check here if attachments Building Photographs See Instructions for Item A6. For Insurance Company Use: Building Street Address (including Apt, Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. Policy Number 4688 Lords Street City Prior Lake State MN ZIP Code 55372 ny NAIC Number If using the Elevation Certificate to obtain NFIP flood insurance, affix at least two building photographs below according to the instructions for Item A6. Identify all photographs with: date taken; "Front View" and "Rear View"; and, if required, "Right Side View" and "Left Side View." If submitting more photographs than will fit on this page, use the Continuation Page, following. : 4. , i r , s" r w.�.�"" �d i 1 , I < S j _ _ _, _ 44 „ 140 _ . 1 , ., , g , °el ,, __ . , „:" "..4:,. 1 .,,,,, 1 - fir` - - - -- _ t ,, . yg l; `��� „ fir ^ - "• x v : . tC. .; ° ' ,, n , P w ; k" View from East (01/06/11) Building Photographs Continuation Page For Insurance Company Use: Building Street Address (including Apt, Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. Policy Number 4688 Lords Street City Prior Lake State MN ZIP Code 55372 Company NAICNumber If submitting more photographs than will fit on the preceding page, affix the additional photographs below. Identify all photographs with: date taken; "Front View" and "Rear View"; and, if required, "Right Side View" and "Left Side View." }' TY � j' f,�'/ y yK/ s � . k / ,• lTt� 4 _' Y14' IN, ..1QE 1 ��. � " X S I - ` ' p !r' 9 4 X 4.. 7 ` �.. saf��' Af/ ,61... 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Mme. b , / v a - , �1+ „pw S ..� - 444,4. <. ._ _ '„'�'.. mss .. :r.,.r.!�^ ,, ,- , ..„r•. - - z . _ - r - . , - ��```4 v` k; any° View from West (01/06/11) • m0 aim E Fn Z m r. p / T � K .. a� `.. � - -¢ l., . -Atha ter ' i' tie y `G ate'+. -cR ^ ' r ,, ° r , � .kw� 4 r e o i .2sTf ,,,` �1 -,7-...-: ,-.M,. stow , -.' ti \ R OA D 1 teavma9G 1 ,...„..„....: .„. ,,.,... .. , 0 �✓ CA vagii lefOr Vilag b oa _ -- — " — -= - -§ - = _ = = _ = 3 3$ � ;� MC g 0 at g�Sa N 9 fmc z,5 1 ' as at !f it: 3 `�� Ca MI o -I 0 Pigs F 3 1 i atilt. 4 krr f ilf d ¢ t i $� 3 i 'i i Pellicci This drawing is neither a legally recorded map nor a survey and is not intended to be used as one. This drawing is a compilation of records, information, and /SCO , }} data located in various city, county, and state offices, J • ` and other sources affecting the area shown, and is to be N t-j r ; ,,_: 1 used for reference purposes only. Scott County is not responsible for any inaccuracies herein contained. If w r•. discrepeancies are found, please contact the Scott ` County Surveyors Office. January 13, 2011 • • Doc. No. A 845896 OFFICE OF THE COUNTY RECORDER SCOTT COUNTY, MINNESOTA Certified Filed and /or Recorded on There are no delinquent taxes and transfer entered Date: 1 1l/ /t^ 01 -26 -2010 at 11:00 Receipt:704051 /,� County Auditor • '�" r 0 U Janice From, Acting County Recorder 01 Title Support Services Fee: $ 46.00 15091 6716 :1'( . MapleG a 55311 Form No. 5-M - WARRANTY D® Individuals) to ,hint Tenants D E E D TAXDUUE R��,I Date: Pt -'I q FOR VALUABLE CONSDB ATION, Cheryl L Patch fka Cheryl L Dombush and Daniel R Patch, wife and husband, Grantor, hereby conveys and warrants to Michael Pellicci and )limberly J Pelltcci, ' Grantee(s), as joint tenants, real property in Stott County, Minnesota, described as follows SEE ATTACHED EXHIBIT A together with all hereditaments and appurtenances belonging thereto, subject to the following exceptions easements, covenants and restrictions of record. ViEI 1. CERTIFICATE RECEIVED Check box it applicable: t" ELL CERTIFICATE NOT REQUIRED ❑ The Seller certifies that the seller does not know of any wells on the above described real property. A well disclosure certificate accompanies this document. CI I am familiar with the property damn bed in this instrument and I certify that the status and number of wells on the described property have not changed ence the last previously filed well disclosure certificate. Affix Deed Tax Sarnia Here UO (d Deed Tax of S s� R Ch L Patch Date_ Conservation Fee Pa ��. ,rg- i�County Auditor !Treasurer • Daniel R Patch STATE O F MINNESOTA , ll-- SS. COUNTY OF - � This instrument was acknowledged before me on ION 2" 1v°1 by Cheryl L. Patch fka Cheryl L Dornbush and Daniel R Patch, wife and husband, Grantor(s). NOTAt ALSTAMPOR `FAL(0ROTHERTITLE0RRANK): _ � �NI JEAN R. ROE L�� aEOFNa _ aRO7}il3t GAL \ � Notary Public-Minnesota Check here liven 1 of OI f the land is Register . (Toms) 0 �"' • M Commlabn Ex rest Jan 91,101 - VW11V Tax Setementsfor the real property dexalbed In this Instrument Mould be sent to tlndude name and ddressorGrantee): THISINS fR1MBJT WAS DRAFTED BY(NAMEANDADD( : Michael Pelllicci Edina Realty Title 6800 France Ave. S,uth 4688 Lords Sreet Northeast • Edina, MN 55435 Prior Lake, MN 55372 -1105 • 4 r • • • • • • • • • • 1 Exhibit A All that part of Government Lot 8, Section 35. Township 115, Range 22, Scott County, Minnesota, tying East of a line to be described: Commenting at a point that is 220.28 feet North and 328.53 feet East of the Northwest comer of Lot 1, Maple Park Shore Acres, said point being on the centerline and East edge of a concrete bridge; thence North 83 degrees 00 minutes East a distance of 129.0 feet thence South 81 degrees 00 minutes East a distance of 112.4 feet; thence North 81 degrees $4 minutes East a distance of 113.00 feet thence North 54 degrees 57 minutes East a distance of 284.45 feet; thence North 73 degrees 17 minutes East a distance of 450.00 feet; thence North 77 degrees 54 minutes East • distance of 290.0 feet; thence one curve to the right having a central angle 0.30 degrees 00 minutes and a radius of 158.8 feat, an arc length of 97.7 feet; thence South 72 degrees 09 minutes East a distance of 2182 feet to the actual point of beginning of the line to be described, said point to be hereafter referred to as Point 'A': thence North 17 degrees 54 minutes East a distance of 99 feet mbre or less to the waters edge of Prior Lake and South 17 degrees 54 minutes West of a distance of 125 more or less to said waters edge. Excepting therefrom the following; Commenting at the above described Point W, thence South 17 degrees 64 minutes West a distance of 25.0 feet to the actual point of beginning of exception; thence continuing South 17 degrees 54 minutes West a distance of 100 feet more or less to the waters edge of Prier Lake; thence Easterly along said waters edge to the Intersection with a line which bears South 9 degrees 15 minutes East from the point of beginning; thence North 9 degrees 18 minutes West • distance of 104 feet more or lass to the point of beginning, Scott County, Minnesota. • • �S-e� 35 —ofa -o B opa5e cI CITY OF PRIOR LAKE Impervious Surface Calculations (To be Submitted with Building Permit Application) For All Properties Located in thy! Shoreland District (SD). The Maximum Impervious Surface Coverage Permitted is 30 Percent. Property Address 1/6 fig Zo zs S S't ee. Lot Area E14., cloy sq. ft. x 30% = l 3 3ZR ***************************************** * * * * * * * * * * * * * * * * * * * * ** * * * * * * * ** LENGTH WIDTH SQ. FEET HOUSE x = x ATTACHED GARAGE x TOTAL PRINCIPAL STRUCTURE 2, ?so DETACHED BUILDINGS .3Ca 4,4s<. X L18( (Garage /Shed) x TOTAL DETACHED BUILDINGS y g DRIVEWAY/PAVED AREAS colt Itc, „ c x ` z, SZ y (Driveway -paved or not) ' x — (Sidewalk/Parking Areas) x • . TOTAL PAVED AREAS 2 , S Z y PATIOS/PORCHES/DECKS 4 /peo 1 x = , '1$9 (Open Decks %” min. opening between x boards, with a pervious surface below, Ail .1 are not considered to be impervious) Cen A,r%ds 1Z4 X - TOTAL 3, 9/S ►"�w .14 0 P / Cent l ?rrr. OTHER x x . = TOTAL OTHER TOTAL IMPERVIOUS SURFACE 9870 6ND—EDOVER 3, y SS Prepared By 5Ca ' M'. .5t.•3' So.i Date ( 17 /id Company UAll.e c t o Cc. IPA _ Phone # ?SZ 941- ZS70 Y L:\HANDOUTS \IMP ERvious.doc