HomeMy WebLinkAboutExcavating & Filling Permit #13-G-05 ���YRlO$
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"'-''�� "EXHIBIT A"
fOR CITY USE ONLY
EXCAVATING AND GRADING PERMIT PERMIT# � - (,=�a�
DATE -t ��� 3
Appiicant ."7Me� �ON��U�-��d�/ Phone#�7 �3f 7/U �
ProjectlDevelopment Name if Applicable: '�'�� /�'��c,�J��I S' ��4��a�i'c �l,c>c � _ .
Address: 2�>t��-�LeS c��^ Qx;��Sv.��e��n) SS3v (o -- ---
Property Owner:�5�, ��;�c�/}��5 l �471���� � N to I Phone# �s2- y'�7� Z 1 / �
Address: I Iv 31I 1`�v�uTh ue �� �r�o� �..4�'ue� /�'I.�iJ. . 55�.7 2-
Ca��tractar._ /"fM C 5 �,v s�t u�����. T�, __ _ Phone ft�.f 2�y3r- ��a�
Address:_z�_1�n,�s 7>�� �,;r.0 S U r��� _� ..�1•tJ �S.3U (o
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Consultant Engineer/Surveyor: ________._Phane!�
Address:
Ernerc�ency Contact(?.4 hr}:1�p.ti1 f-�M �S _ Phc�ne#���-�Z O ` 5���'�
Locatian of Property: I�� f I �U'cJ� /�F�Je �� _ _, .
Legai Descripiion• _._ __ . __
Wiil#he excavatian or filiing be in a: Watercourse +U o Wetland �� Upland N�
PurE�ose€or the proposed excavatir�g ar filling: 'piq�l q ra�ti J �Z�GpN:57r Uc7�r o.v
Estimated start date: J�� 1 S 2 c I 3 Gompfetian date: Au�,, Z G Zo r 3
iNhat is the type of material to be removed or depasiteci? ��/-Fc k ���T
Wh�t is the quantity of material to be removed or deposited?_��_�.._���d.5
WI7at is ti7e total area disturbed far excavation or fiilinc�? .� _ _
13i what manner will the materiai be removed ancllor deposited�,r=,u,�,e e� .� rpMa 1;
What highway,street or other public-way wif(material for removal or cteposition be hauled or carried? __ . ____
What,if any,street,avenue,lane,al(ey,highway,right-of-�vay,thoroughfare or p�iblic grounc!will be obsiructed?
IT SHALL BE THE RESPONSIRILITY ANU l t-IE BURDEN OF THE APPLICANT TO DEMdNSTRATE TO TNE SATIS(-ACTION
OF THE CITY ENGINEER FOR THE CITY OF PRIOR LAKF THAT THE PFtOPOSED EXCAVATION AND/4R FILUNG
COMPLIES WlTH TFiE OVFRAI_l. CITY OF PRIOR tAKE STORM WATER MANAC�MENT PLAN. SAI� BURDEN SHAIL
INCLUQE THF FURNISHING QF A REPORT WITH SUPI'ORTING CAICULATIONS t7F A RECUISTEREO PROFESS10tUAL
ENGINEER.
Will proposed excavation or deposition affect ihe City af Prior Lake oveialf stann water m�nagement plan� Yes, _ No��/
If yes,explain proposed effect` _ ___ ____ ____.
SUBMISSION f2EQUIREMENTS:
(R) Completed application form
(F3) Map or plat of the propased fiiling or excavating showing locatiai anci amount of r7�aterial proposed to be removeci or
deposited,with a description of the area
(C) The depth or heights ta wt�ich such removal or depasition is E�roposed throughout tiie area anci the�roposeci �ngle of
ail sla�es to be shown on a 2'contour map at a scale o(1"-5Q'ar larc�er The proposed and oric�inai contours sha11 be
G lad-nin P5l'Dr_iZn St>nu iL?t�)7 pND>t[4'U.qT 6�F Xliti3it A Af'S'1 ICA I IO\F U:L EXL`A\'&Fl l I t\G e'���
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'���"' «EXHIBIT A��
shown including all properiy within 200' of proposed excavation or cieposition and shali be signed by an engineer or
surveyor registered in ihe Staie of Minnesota
{D) Erosion control plan
(E) Affect on existing utilities
(F) Applicai�on fee
{G) Amount oF Letter of Credit, or deposii of monies in a sum su(ficient to pay lhe cost of restori�y a sito. The exlra
ordinary costs oi 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 ro be cione
(H) Public liabilily fnsurance
GONDITIONS OF liPPROV$L;
(i) Applicant must call itie Engineering Department for erosion control inspection ai(952.)447-9630 prior to earth moving
activities.
(2) Maximum 4:1 slopes are allowed in "maintained" areas except appraved by City Engineer. Maximum 3:1 slopes are
aflowed ad�aceni natural resources.
(3) 5lopes greater than or equal to 3:1 shail have approved erosi�n control Best Managemont Practices instalied
immediately atter finished grading
(4) Minimum grade ior drainage swales shall be 2%or greater.
(5) Removai or depositing oi material greater than 440 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 ouilined hy other permilting agencies including but not
limited to ihe foilowing: DNR, Corps o(Engineer, Prior lake/Spring Lake Watershed Uistrict, Scott Coimty, MNIDOT,
MPCA.
(7) Applicant is res�onsible for all damages to ofher property or facihties as a result oF work covered by this permit
(8) Applicant musi cali the Enginesring Deparlment(or final c�rad'+ng inspection at(957_)4�17-9830 prior to release of grading
security.
(9) Additional Canddions:
THE UNDFRSIGNED HEREIN CERTIFY THA7'THEY HAVE READ SECTION 706 OF THE CITY CaDE AND ACCEPT THE
TERMS AND CONDITIONS TO THE 15SUANCE OF THIS PERMIT AND AGREk TO FULLY COMPLY TNEREWITH TO THE
SATI5FAC710N OF i'HE CITY OF PRIflR LAKE ENGIN[ERING DEPARTMENT OR I iS UESIGNAT[D/iG[NT.
Applicant:--1-`,�'� �G� Daie �w/� �� . ao�3
— --- - — �-
Property own�r�, 1�'?—,�..,�_ti t,,y_�� C��—f-'1�..1�c.. �� l.���,l - Daie��_j���' i3
FOR CITY USE ON�Y
' ! � AUTHORIZATfON OF PERMIT
Financial Guarantee Arnount� Financial GuaranteQ Type� _(Letter of Creciit, Bond,or Cash)
Permit Fee 5 �n�
Liability Insurance provided? YesO No(Insurance Certificaie must name the Ciiy of Prior Lake as an additional insured party)
In consideraiion of agreernent to compiy in all respects with the regulations of the Cily of Prior Lako covering such operations,
and pursuant to auihorizat+on 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 applicalion and
submitted draw+ngs.
ENGINE[RING OFFICIAI Date,
Permit is valid if sic�ned by City Official � `Z �� �
_Permit Expiration Date_ (a�/ � t 3 _ Pianrnng Dept.Initiais _
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Client#: 57 AMESCONI
ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDMlYY)
7/12/2013
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 COVERAGE 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 NTA T
NAME:
MN-COMMERCIAL LINES PHONE 612 349-2400 F'0'X 672 349 2490
A/C No Ext: AIC,No:
COBB STRECKER DUNPHY&ZIMMERMANN E-MAIL
ADDRESS:
150 S FIFTH ST STE 2800 INSURER(S)AFFORDING COVERAGE NAIC#
MINNEAPOLIS, MN 55402 iNsuRERA:TRAVELERS INDEMNITY OF AMERICA
INSURED iNsuRER B:TRAVELERS PROPERTY CASUALTY CO/
AMES CONSTRUCTION INC
2000 AMES DR INSURER C:
BURNSVILLE,MN 55306 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.
�7RR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY
A GENERAL LIABILITY VTC2HC074086632 5/01/2013 05/01/201 EACH OCCURRENCE $���������
X COMMERCIAL GENERAL LIABILITY DAMA E 7O RENTED
PREMI ES Eaoccurrence $3�����
CLAIMS-MADE �OCCUR MED EXP(Any one person) $rJ,���
X CONTRACTUAL LIAB PER PERSONAL 8 ADV INJURY $��OOO�OOO
X POLICY FORM AND XCU GENERALAGGREGATE $Z,OOO,OOO
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $Z�OOO�OOO
POLICY X PR� LOC $
JECT
B AUTOMOBILE LIABILITY VTC2JCAP5834B489 5/01/2013 05/01/201 COMBINED SINGLE LIMIT
Ea accident �r���r���
X ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
X HIREDAUTOS X NON-OWNED PROPERTYDAMAGE $
AUTOS Per accident
$
UMBRELLA LIAB pCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
B WORKERSCOMPENSATION VTC2JUB6726B789 5/01/2073 05/01/207 X WCSTATU- OTH-
AND EMPLOYERS'LIABILITY
B ANY PROPRIETOR/PARTNER/EXECUTIVE Y�N VTRJUB83646757 5/01/2013 05/01/201 E L.EACH ACCIDENT $� 0�0�Q�
OFFICER/MEMBER EXCLUDED7 � N/A
(Mandatory in NH) STOP GAP LIABILITY NLY IN STATES E L.DISEASE-EA EMPLOYEE $�,OOO,OOO
If yes,describe under OF: ND OH WA WY E.L.DISEASE-POLICY LIMIT $��Q�Q��00
DESCRIPTION OF OPERATIONS below
DESCRIP710N OF OPERA710NS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required)
LICENSE/PERMIT REQUIREMENTS
CERTIFICATE HOLDER CANCELLATION
CITY OF PRIOR LAKE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
16776 FISHPOINT RD ACCORDANCE WITH THE POLICY PROVISIONS.
PRIOR LAKE,MN 55372
AUTHORIZED REPRESENTATIVE
0 CORPORATION.All rights reserved.
ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD
#S535650/M521561 CJS