HomeMy WebLinkAboutExcavating & Filling Permit #12-G-08 .
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� � �� EXHIBIT A ��
FOR CITY USE ONLY
EXCAVATING AND GRADING PERMIT PERMIT# �--o�
DATE f - 1- I ,�
Applicant: � (�,� °I Y� Q�'� 1 I✓«1 Phone #` I�'`t' �a ' c-�� vU
Project/Development Name if Applicable: �..��� T� �� l� � C K- _�
Address: � 1�.�� �1V�'�WI �el��$, �'I►'fiLl � cSfi1i�, ��'j0� ��t�G� y'1��� JJ.37�
Property Owner. � � l��- � � �%V i V �''v� �"1 Phone # � J� '- l �``f' � ! S��
Address: �,��CIC l�C�r✓�4vh S ncvfs rtvcc.r' f fi�� �' ��-�o�- t��� v�� J53�7a
Contractor: �� ✓� �il � "1 � � Phone # ��� ��a �i�
Address: N' V �'1
C "
Consultant Engineer/Surveyor: Phone #
Address:
Emergency Contact (24 hr): �� � {7 �vi�� V v 1 Phone # �� ;7�'cJ�J !
Location of Property: �Q�C.I `�Cl� (i'�'1 �1�17�1' / (�Y(D1/ �.G�t�� 6•f't �7v�'e`1 1����/11�1�' �V�l �
Legal Description: � ���"� a� t o a�a a� � c'� V P�r? �'I'e� ��'I �3 � a -� iyU�l�/ C�'b'I
Wiil the excavation or filling be in a: Watercourse Wetland Upland
Purpose for the proposed excavating or filling: �'f �Q �� `�'� I�S T1� Y101 � Gl,WIvISC�� ��l
Estimated start date: "1� 5 1� � Completion date: ���
What is the type of material to be removed or deposited?���• I�VYI� Q��A.In1�C �UG1� I 0 �'�' Bocid�v�l e��n„y �`��
What is the quantity of material to be removed or deposited?
What is the total area disturbed for excavation or filling? .J -
In what manner will the material be removed and/or deposited? G
What highway, street or other public-way will material for removal or deposition be hauled or carried? �� '1ZGI ZI
What, if any, street, avenue, lane, alley, highway, right-of-way, thoroughfare or public ground will be obstructed? 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 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:WdminU'W Dcsign Manua1�2007 PWUM UPDATE�XHIBIT A APPGCATION FOR BXCAV & FILLING.dce
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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 uti�ities
(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�47-9830 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 HE, RTIFY THAT THEY HAVE READ SECTION 706 OF THE CITY CODE AND ACCEPT THE
TERMS AND CONDITI NS T E ISSUANCE OF THIS PERMIT AND AGREE TO FULLY COMPLY THEREWITH TO THE
SATISFACTION OF T Y PRIOR LAKE ENGINEERING DEPARTMENT OR ITS DESIGNATED AGENT.
Date � � � l `�
Applicant:
Property Owner. ��1.� a"�-� �`' Date
FOR CITY USE ONLY
AUTHORIZATION OF PERMIT
Financial Guarantee Amount $ Financial Guarantee Type �,.`iE�.n �'�(7 (Letter of Credit, Bond, or Cash)
Permit Fee $ !�d-d(�
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 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.
Date �!'�
ENGINEERING OFFICIAL
Permit is valid if signed by City Official
Permit Expiration Date 1"�'�.� Planning Dept. Initials SIY`�"`�
G:WdminU'W Dcsign Manua1�2007 PWDM UPDATE�XNIBIT A APPLICATION FOR EXCAV & PIrLZLING.dce
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shc»wn �rx�u�?ing �If �perty wi�r;in 2t1l3' a€ pmpxraod excav�#iUn or t�op�sition a�ci shafi ba signc�ri by ar. enginr-;ar rn
surveyor r�istr,rc;d in lt�r .Staxe �f A�innesata
;1�j Ernsio;i ccnkrc3l piart
(�) Affect ar► existir� ut'Ittie�
;f') ApPlicafion �e
{CJ Amount of Lerer of Credi� srr dr�po,sit c:f monie5 in a s�..{m sufficieni to �ay thr xst oi restc�ring a site. Thc: �xtra
ardtna.ry cnsts at re�z�i!�n�, highway�, sFrnt�fs ar ot�er �ublic utays alona dn.Rignated rnuies c�f travel and ta pay sucl;
cxpenses aa the C{tar may ir,c:irr by reasnn pf dnin� anylfiin,y mquired to be dpr.c�
(6-�� Public 1i;�7tiiiy ins:ira��:
�(�hIL31T'lONS CT' APRROV�'�L:
(93 AC�piieanf mi�Pt :afatt the �ngfn�:ar;n� Oenr3tt;:�ont fo^ erosio^ cs:nfrol ins�eotion at (y5?.)ti47-98�0 pricx ta earth mnving
ac�ivities.
��; fiAax`rrum 4;9 slo��rs ::ire ta3in,�ued in "mairit arc�as nxr.Apt ap�rnv�d �y Glty En�}inecr. fi4aximuYr, �:i sla�g �arr,
nlPciwed AdJscer� natura" resr.c;rces.
(3} SiUpc:s c�re�►faT tEz:�n nr equ�+i tca 3.' shalt havi: :��rovec ere�t;ion MrantrQF �esf ManA�emen# ?rae:fieas instaNed
in�mecit�idy efter tlrished g�adin�.
(�7) • Mirhmum g�ar;o t'i� drxiinac�� swral�as sti�dl Be ?.� o: gr�rai,er.
(ti; Ftemov�! c�r �epr3.si�ing o? materi�. �rcat�r tl�n 4UU c:uh€c yarsis cQquirass � aonclift�ai usc J�r.: mit, �.rrtless ,t is aart nf a
Nr�limL��ry pEat �pplie�ticsn.
(Fi} Appfic�n# �S rr.spe�nsi5(e� Fvc r�htainir� and mc�eiing the candittr_ns sw8ir�iarl �:y uth+cx p�miittir�{} sgcsr!c.Er.�a i��luding but nat
timited tc� tho fatk�w:r�n: G!V'r2, Cc�rps of �ngincx:r ?rin- t�kelSpring L.ake Writa�rstw3ct Qistrtt�, S�att Cna�nty, MNi�q7,
�1PGA.
;?) AppCocant is rr::sr���sib(�: fi>r a}i dama�es 4c nthor propnrty rar f��lEdcss as ��siaR o! wark cnvored by this pornit
i�) �PAtir.�ttt t?zust �tti( tht� �nginesring Dr.pattment fnr firial �racsirsg k►stx:cficr at (9K2}4.47-883t3 ��iic�t to r�;eas� af gra�i�e,r,
ser.;itity.
{S; Aticitinn�! f„ondttk�rts: ,� _
7'EiE �.iN�3EEt.rilGtiF.[7 HE "° R"'I�Y � HAT �fH�Y IlAVE READ SECTIOh 70& C3F 'iii� Cf1Y GAflF AND ACGEPT 11fE
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uA7'1SFAGTI(JN f3� T•_ PiZIbR LAK� F:N�'.i�tE�RINCy t7CPAi2'tlViE�!7 t7� iTS ilk8?GAWTE� ltG��lT.
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� ��inz�naai Gu��rotne Arncxtnt � _.., �inaruuaai Guerr�rrtee Type,__ (i.ett�rs�f Credit, �onc, c;r t'.ash)
Fcrmit �ee $
L'��bil�ty InRE�r�nc�.� pruvi�r�ci? O Yes[� Nc jlnsurr�ZCO Ce; '6f'ic,ata must n�me ih�a Ciry af P►iar t.�ke as an aKidltlanra! �rsurc:d party}
in cor��Pderat�nn of �reemr.n# to cxm�p(y in sii r.^.specf.a wilt� the regulatians afi the Gi;y nf Pri4� Lalce ^.rsvering ;sa�ch o�x:r�'ions,
� snd puc:suant fo �su.horfiati�n s�t.ty �ivr.n !sy said (;ity of PrEnr :.ak�, pcsrmission is hereby grante�3 ior the work i,� �a dune as
ricscritxsd in t,hr. abevc: ap�Gcatic,n and s��;xrd#.c�d slrawir�s, s�ifl work t� Ex: done i�t arx;r�rd�nc� with this appliration and �
sut�mlt�ert �i�w�nqs. �
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'4`_°R° � C E RT I F I CAT E O F L I AB I L I TY I N S U RAN C E DATE (MM/DD/YYYY)
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THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERACaE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER 507-931-4482 CONTACT
NAME:
The MacKenzie Agency PHONE Fnx
P.O. Box 120 ac No eXe : �uc, No :
St. Peter, MN 56082 E
Ben Griffith ADORESS:
PRODUCER FINAGRA
CUSTOMER ID #:
INSURER S AFFORDING COVERAGE NAIC #
INSURED Final Grade, Inc. iNSUReRn: Acuity - A Mutual Compan 14184
3441 Bluff Drive INSURERB:
Jordan, MN 55352
INSURER C :
INSURER D :
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT 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 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE �DL UBR POLICY EFF POLICY EXP LIMITS
LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY
GENERAL LIABILITY EACH OCCURRENCE $ 'I,OOO,OO
A X COMMERCIALGENERALLIABILITY K86262 03/07/72 03/01/73 pREMISES Eaoccurtence $ 100 ,��
CLAIMS-MADE � OCCUR MED EXP (Any one person) $ $,��
PERSONAL & ADV INJURY $ � �OOO,OO
GENERAL AGGREGATE $ 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ Z,OOO,OO
X POLICY PR � LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ��OOO�OO
(Ea accident)
A qNY AUTO BODILY INJURY (Per person) $
ALL OWNED AUTOS BODILY INJURY (Per accident) $
X SCHEDULEDAUTOS K86262 03/01/12 03/01/13
PROPERTY DAMAGE $
X HIREDAUTOS (Peraccident)
X NON-OWNEDAUTOS $
$
UMBRELLA LIAB X OCCUR EACH OCCURRENCE E Z�OOO�OO
EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,00
A K86262 03/01N2 03/01/13
DEDUCTIBLE $
RETENTION $ 3
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS' LIABILRY
A ANYPROPRIETORIPARTNER/EXECUTIVE Y � N K86262 03/01/12 03/01/13 E.L. EACH ACCIDENT $ 5�0,��
OFFICER/MEMBER EXCLUDED7 ❑ N / A
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ $�0,��
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ SOO,OO
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Altaoh ACORD 107, Additional Remarks Sohedule, H more space is required)
CERTIFICATE HOLDER CANCEILATION
Cit of Prior Lake ISSUEDT
y SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
4646 Dakota Street SE ACCORDANCE WITH THE POLICY PROVISIONS.
Prior Lake MN 55372 AUTHORIZEDREPRESENTATNE
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