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HomeMy WebLinkAboutExcavating & Grading Permit 14-G-8 "EXHIBIT A" i •;;u 0; ' " FOR CITY USE ONLY _ l L f� PERMIT# 1 4- �b - rti,.t,x,,_., ,,\ DATE , EXCAVATING &GRADING PERMIT �(C. 55 lo1 — 05' ei pf 72-4.07 . Applicant: Cjr)r S 00.t..-e Phone: CC'-) ` 3T`l / 7 J-• I — Project/Development Name if Applicable: I` (o`t 0 Vf^C'CANci feeiaCA A U Z --- Address: — Property Owner: r;', C)c,.A---P Phone: — [ SOS � � s3 1-- Address: s��� GJ � � 7 — Contractor: 1304-Ay1 t 'c- Phone: Address: 31 t 5 44"/".cor re--) -) fl$3y &Z , *K) 55. 2ci — Consultant Engineer/Surveyor: Phone: — Address: • Emergency Contact(24 HR): Phone: _ _ o�/l c) (4.�9 mace., ✓� ,,� , P� Location of the Property: � 1e — Legal Description: Will the excavation or filling be in a: Watercourse Wetland Upland — Purpose for the proposed excavating or filling:. 157O/i r"t (1-4;0114, Estimated start date: 6./1 / y C pletion date: VI //'d f" DAD•'.l424,t' What is the type of material to be removed or deposited?4-4 I tl i Pt(' — What is the quantity of material to be removed or deposited? -re0A — What is the total area disturbed for excavation or filling?a5v �c N c kore4 In what manner will the material be removed and/or deposited? - C0,,,t,noCkr What highway,street or other public-way will material for removal or deposition be hauled or carried? j 3 Do c AJi2ar en_ What, if any,street,avenue,lane,alley, highway, right-of-way,thoroughfare or public ground will be obstructed? IT SHALL BE THE RESPONSIBILITY AND THE BURDEN OF THE APPLICANT TO DEMONSTRATE TO THE SATISFACTION OF THE CITY ENGINEER FOR THE CITY OF PRIOR LAKE THAT THE PROPOSED EXCAVATION AND/OR FILLING COMPLIES WITH THE OVERALL CITY OF PRIOR LAKE STORM WATER MANAGEMENT PLAN. SAID BURDEN SHALL INCLUDE THE FURNISHING OF A REPORT WITH SUPPORTING CALCULATIONS OF A REGISTERED PROFESSIONAL ENGINEER. Will proposed excavation or deposition affect the City of Prior Lake overall storm water management plan?Yes— No If yes,explain proposed effect -- �® �� 0)? �,� ice, "EXHIBIT A" 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 shown including all property within 200' of proposed excavation or deposition and shall ae signed by an engineer or surveyor registered in the State of Minnesota D. Erosion control plan E. Effect 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: A. Applicant must call the Engineering Department for erosion control inspection at (952)447-9830 prior to earth moving activities. B. Maximum 4:1 slopes are allowed in "maintained"areas except approved by City Engineer. Maximum 3:1 slopes are allowed adjacent natural resources. C. Slopes greater than or equal to 3:1 shall have approved erosion control Best Management Practices installed immediately after finished grading. D. Minimum grade for drainage swales shall be 2%or greater. E. Removal or depositing of material greater than 400 cubic yards requires a conditional use permit,unless it is part of a preliminary plat application. F. 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 Coun':y, Mn/DOT, MPCA. G. Applicant is responsible for all damages to other property or facilities as a result of work covered by this permi.:. H. Applicant must call the Engineering Department for final grading inspection at(952)447-9830 prior to release of grading security. 1. Additional Conditions: — THE UNDERSIGNED HEREIN CERTIFY THAT THEY HAVE READ SECTION 706 OF THE CITY CODE AND ACCEPT THE TERMS AND CONDITIONS TO THE ISSUANCE OF THIS PERMIT AND AGREE TO FULLY COMPLY THEREWITH TO THE SATISFACTION OF THE CITY OF IOR LAKE ENGINEERING DEPARTMENT OR ITS DESIGNATED AGENT. Applicant: . � Date 511geiq — Property Owneri-4 Date 5/ 2 N g 1 "EXHIBIT A" IMPORTANT BEFORE STARTING WORK EXCAVATOR AND OPERATOR'S NOTICE This notice is to inform excavators and operators they must comply with Sections 2160.03 to 2160.07 of MINNESOTA STATUTES Call Gopher State One Call(BOO)252.4166 or 651-454-0002. Or go to www.gopherstateonecall.org Smart Phone: httzffinnticketentrv.korterraweb.com FOR CITY USE ONLY AUTHORIZATION OF PERMIT Financial Guarantee Amount$ Financial Guarantee Type (Letter of Credit,Bond or Cash) Permit Fee$ /00.00 Liability Insurance provided? Yes El 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 awings. ENGINEERING OFFICIAL Date Permit is valid if signed by City Official PERMIT EXPIRATION DATE(90 days from approval date) sg2g_/1 Planning Dept. Initials i' '4R CERTIFICATE OF LIABILITY INSURANCE 5A28i2o1"4YY) 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,su''bject 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 CONTACT NAME: Scott Endorf CPCU CIC Bullis Insurance Agency, LLC (A/C. f,f). (952)449-0089 A/C No):(952)449-0.208 407 East Lake Street #201 ADDRESS:sendorf@bullisagency.com P.0. Box 704 INSURER(S)AFFORDING COVERAGE NAIC# Wayzata MN 55391 INSURERA:Cincinnati Insurance 10677 INSURED INSURER B: Botanize, Inc. INSURERC: 319 Shiinmcor St. INSURERD: INSURER E: Mayer MN 55360 INSURERF: COVERAGES CERTIFICATE NUMBER:2 014 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 REDU CED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP WLIMITS LTR INSR VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ A CLAIMS-MADE X OCCUR EPP0133691 4/1/2014 4/1/2015 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 Ro- POLICY n jT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 A X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED EPP0133691 4/1/2014 4/1/2015 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS x AUTOSED (Per accidentDAMAGE $ Uninsured motorist combined $ 1,000,000 UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N X TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? Y N/A (Mandatory in NH) WC2137400 4/1/2014 4/1/2015 E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) CERTIFICATE HOLDER CANCELLATION nbriese@cityofpriorlake.co SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Prior Lake ACCORDANCE WITH THE POLICY PROVISIONS. 4646 Dakota St. SE AUTHORIZED REPRESENTATIVE Prior Lake, MN 55372 Chris Biehle/CB ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(7nInn5)nt The tinnizr1 name and Innn arc rcnicfarad markt of Ar'l1RIl T7.,... ... • • . ,r, ..... ,..s., ,.., ,...x ., „. , . . ... ...• , t, ri, . . 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