HomeMy WebLinkAbout3F - Lloyds Construction Services Refuse Hauler Permit
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State of Minnesota, t ~f -fJAL7' ~
County of Jd l ". Office of tf./'t '-fr1~ ,ur
~ '1k"""--TPermit. ,
IN CONSIDERATION OF statemen made ~ 1\l-t1dJ tnuJt~,>"-../
I
upon that tract of land described as follows: Lot Block
Address
which tract is of the size and area specified in said application.
. plat or addition
This permit is granted upon the express conditions that said owner and hfl- contractors, agents, workers
and employees, shall comply in a~ects with the ordina~s of the
_ of '/U/V ~
Given Imder the hand of the ~ '-IJ la~l ~ of said %
seal and attested by its "-ry 4A<j this 4/ ~ day of ~~......... ./'\L...,
Attel"t:
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c ~ I Y ()I I'll i r ill I ,\h I
lit,,") IJdkul.1 ~lr('t' :,1 . 1'1) II", \']')
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.\PPLl C,\ 11011 I UH A C,\HliM:L ~ IU I US[ H.\lJL J lie 11 U 11<)[
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Ordinance U72-?
Appl icant LJotJ ~ C,~>-tl ~\1I ,v'S. 11\(_.
License tlum!>l'fS
1 ruel.; Ildke
T roJ i ICf rl,-,~
r-1dllager's ndmc if different than applicant
:t:,h, L{ '> J 6r :s \ (Y\ U ~ j6 -
Firm Name LIVY..J.s (~",,+ ~';),~' ,I!G
Address }-;-6X6 S NIt'I'. 8L~. p{',_rlLu)3.
mA, <)S'S-'d-. 4.
l.W ~g4~ 8
tP
2.
]1" t~r/1lt.~ ..",t1-1
Y/A
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JJ~ f:) -,;;'
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Telephone Number
Heceipt t~umber
License Number
4";0- :::~3d
0"
I.{ Lt :
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5.
n.
Charge
Charge
Charge
Charge
First Truck $100.00
Each Additional Truck 25.00
Roll Off Containers 25.00\~
per residence per year for once a week pickup
per residence per quarter for once a week pickup
per residence per month for once a week pickup
license Fee:
~ .
CharJe on a call basis only
Other
s :>:~)
s tj';1
s tJ / -
!
S jj/ A
S /J !~
to ~ 6 ~j(j
for commercial per year for twice a wee~ pickup
. -
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PROPOSED CHANGES IN CHARGES DURING THE LIFE OF THIS APPLICA nON I-lUST BE SUSrlITTED TO THE CIT ~
Contents of (Haximum Number)J\)I..:- dumpsters 1 cubic yard or larger \\ill be picked Ul
per stop at each commercial establishment or apartment house.
Amount of materials to be picked up at residence once a week in terms of number of garbage
receptacles and refuse: I ) / j'.,
Days which your trucks will pick pp in the City: ~~.. /-it1 / ,11\ .,
, / /
Number of customers: iO }ki.V r~1'>'L S", ~ ~r"'-"
Time of day ~ickup will be made: 6/'.1""\ to It) PM
INSURANCE POLICY (Ol{ COpy) r-1UST IJE ATTACHEO TO THE APPLICATION.
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A CERTIFIED BOND IU THE SU~I OF 51,000.00 FuR EACH VCHICLE HUST OE FILED WITH THIS '\PPL IC'\TIOt,
INSUHo\NCr. !-lUST dE PiW\'WF:D 10 cn\'iR :\L1_ Vnl'CLfS: 11iflimum S IOO.UOO.DO (',lell persofl ifl5\1!
JOn,ODO.OO (',\ell uccid('nl
?). 000 .00 prop('l'ty d,Im,llJ('
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rhl'rc :,11<..111 1Jl' no t'tlulinC) jrl Lk City for hirf' from rl'~id('nti.tl dl'ldlinfJ uniLs 1.H.:tW{T/1
Ut(' hours <.lfl<:r 7:UU I'll or lj(.fure 7:uu r\H 011 allY da). Tllcre Sh.lll be 110 qarbagc or
n.:flJ~e picku~ from residentidl d'H'lling Ullit rcsidcfi"cs Oil Sunday. Refuse c.lIld gJrbal]('
frum re::.idential areas mJ} oe ~ick(;J up from one place at CJround level ddjdct:nt to the
street or alley, but deposited off tile traveled roadwdy.
I (l'Ie) Ilert.:by agree to opt:rdle such business in accordance wi tl, the laws 0 f Millnesota
dnd the ordinances of the City of Prior Lake. The foregoing statements .:ire true and
correct to the best of my knowledge and belief.
FIRt.1 NAl.IE L I -,. ~.
YOUB AUTHOiUIEO SIGtj^ TUnE
PuSIT IUI~
{;t7~
d~... ..j--
/3\ r791
DATE
C t1l.r~ \01
/
Approval by City Manager:
Approved
()~'f- 2-,(g-Clj
Approval of City Council
At~ttltl..
~UCt:R
Highview Insurance Associates, Inc.
P.O. Box 1407
Burnsville, Mn. 55337
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORM I L Y AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
COMPANY A
LETTER
United Fire & Casualty
INSURED
COMPANY B
LETTER
Lloydls Construction Services, Inc.
15157 Fish Point Rd.
Prior Lake, Mn. 55372
COMPANY C
LETTER
COMPANY D
LETTER
COMPANY E
LETTER
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
CO
LTR
POLICY NUMBER
POLICY EFFECTIVE rOLICY EXPIRATION
DATE (MM/DD/YY) DATE (MM/DD/YY)
TYPE OF INSURANCE
GENERAL LIABILITY
X COMPREHENSJE FORM
X PREMISES/OPERATIONS
UNDERGROU,,"D
EXPLOSION & COLLAPSE HAlARD
X PRODUCTS,CCMPLETED OPER
X CONTRACTUAL
X INDEPENDENT CONTRACTORS
X BROAD FORM pqof>ERTY :;AMAGE
7-23-91
BODIL Y INJURY OCC
BODIL Y INJURY AGG
PROPERTY DAMAGE OCC
PROPERTY DAMAGE AGG
BI & PO COMB;NED OCC
BI & PO COl.4BINED AGG
PERSONAL 'NJuRY AGG
20-094 081
7-23-90
PERSONAL 1>_ _RY
I AUT~MOBILE LIABILITY
ANY AUTO
X ALL OWNED AG-OS I p,;, Pass !
X ALL OWNED A 0 70S I ~,:e'p:::n,
X HIRED AUTOS
X NON.OWNE!) A~ TOS
GARAGE LlA6 _ TV
BeDil Y !NJUR'f
I Pl?' ;ierson'
12-002 608
8-13-90 ,8-13-91
BODIL Y INCURY
,p~r accIOe":
: PHOPERT'" ~A\(AGE
BODILY IN.JuRY &
PROPERTY DAMAGE
COMBINED
EACH OCCe-RRENCE
AGGREGA TE
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN _MBRELLA FORM
WORKER'S COMPENSATION
STATUTORY LIMITS
EACH ACCIDENT
AND
EMPLOYERS' LIABILITY
DISEASE-POLICY LIMIT S
DISEASE-EACH EMPLOYEE S
OTHER
DESCRIPTION OF OPERA TIONS/LOCA nONS/VEHICLES/SPECIAL ITEMS
LIMITS
S
S
S
$
$ 300 000
$ 600 000
$ 300 000
$
500 000
000 000
250 000
$
S
CERTIFICATE HOLDER CANCELLATION .
City of Prior lake
4629 Dakota St. SE
P.O. Box 359
Prior Lake, Mn. 55372
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF. THE ISSUING COMPANY Will ENDEAVOR TO
MAil -.15L DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
lEFT, BUT FAilURE TO MAil SUCH NOTICE SHAll IMPOSE NO OBLIGATION OR
LIABiliTY OF ANY KIND UP HE COM PAN ,ITS AGENTS OR REPRESENTATIVES.
. . .
ACOlllt.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORM I L Y AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
~RODUCER
Highview InsuraGce Associates, Inc.
P.O. Box 1407
Burns'.'i lle, Mr!. 55337
COMPANY A
LETTER
United Fire & Casualty
INSURED
COMPANY B
LETTER
Lloyd's Construction Services, Inc.
15157 Fish Point Rd.
?rior Lake, Mn. 55372
f~~~~NY C
f~~~~NY D
f~~~~NY E
COVERAGES
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
CO TYPE OF INSURANCE POLICY NUMBER I POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE IMMiDDiYVj DATE :MMiDD/YY)
GENERAL LIABILITY I BODIL Y INJURY OCC S
>-- 20-084 081 I 7-23-90
X COMPREHENSIVE FORM 7-23-91 BODIL Y INJURY AGG S
'-- !
^ PREMISES/OPERA TIONS PROPERTY DAMAGE OCC S
- UNDERGROUND
, PROPERTY DAMAGE AGG is
- EXPLOSION & COLLAPSE ~AZARD
1 ~RODUCTS/COMPLETED OPER BI & PO COMBINED OCC is 300 D(li:
X CONTRACTUAL , BI & PD COMBINED AGG S (,nf! nnn
x ,NDEPENDENT CONTRAC:;RS PERSONAL INJURY AGG S ~(l(i 'If I)
.........:.-.i
^ i BROAD FORM PROPER'" :..'AAGE
.........:.-.i
, PERSONAL INJURY
AUTOMOBILE LIABILITY I BODILY iNJURY
I: ANY AuTO S
i ;Per oersar1) , S!/n (\-\,-;
~ ALL OWNED AUTOS pr.. Pass I ,2 -OC12 t-,.......,." e-13-91~ c, - i J - _'1 I BODILY ;NJURY
,)'f, S
, ^ ~ ALL OWNED AUTOS, Or"'-:' i"'ar. (Per acc:ce""; 1 ("Ii," '~,.!r,
~ p'. Pass
;: "IRED AUTOS , I
~ ! PROPERTY DAMAGE S I
X 'NON OWNED AUTOS i i / '-,: : :,- .....
r--:--- I BODILY :NJURY &
f-- GARAGE liABiliTY pROPER~Y JAMAGE S
COMB'NED
EXCESS LIABILITY ; EACH OCCURRENCE S !
~ ! AGGREGATE
---.,; JMBRELLA FORM , i ' s
'OTHER THAN UMBRE.cA FORM ! i I
I : ! STATUTORY LIMITS
WORKER'S COMPENSATION I
I EACH ACCiDENT :s
AND
DISEASE -POLICY LIMIT S
EMPLOYERS' LIABILITY DISEASE -EACH EMPLOYEE: S
OTHER
I
i
DESCRIPTION OF OPERATIONS LOCATlONS/VEHICLES/SPECIAL ITEMS
CERTIFICATE HOLDER CANCELLATION .
c ~ ~y
:: j~~~~
(.f ;-)~'.i)i'
I ''''6
.......i'\...
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL 1 (1 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBliGATION OR
LIABILITY OF ANY KIND UPQN THE COMPANY, ITS AGENTS OR REPRESENTATIVES
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~dl-':o"l.,a S'~. SL:
B0l: 2S~:;
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S~;:l72
AUTHORI~~~ rESENT~"VE_ '
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ACORD 25 (7/90) t ACORD CORPORATION 1990
form 5P: C I
LICENSE APPLICA~T:
~ursuant to ~innesoca Statute 270.72 lax Clearance: Issuance of Licenses.
the I icensing autnori~y is reQuired to provioe to tne ~inneso~a
Commissioner o. ~evenue your ~innesota busIness ta~ loentification numoer
and t~e soc1al seCJrity numoer of eacn I icense aD~1 lcant.
Unaer tne ~innesota Government Data Practices Act ana the federal Privacy
Act of 1974. we are reQuired to advise you of the fol lowing regarding the
use of this Information:
I. This information may be used to deny the Issuance. renewal or
transfer of your license In the event you owe the Minnesota
Department of Revenue oel InQuent taxes. penalties or Interest;
2. Upon receiving this information, the licensing authority will
supply It only to the Minnesota DeDartment of Revenue. However,
under the Feaeral EXChange of Information Agreement the
Department of Revenue may sUPply this Information to the 'Internal
Revenue Service:
3. Failure to supply this Information may jeopardize or oelay the
processing of your licensing insuance or renewal appl icatlon.
Please supply the fotlowing Information ano return along with your
aDDI ication to the agency issuing the 1 icense. 00 NOT RETURN TO THE
DEPART"ENT Of REVENUE.
LICENSE BEING APP~jED FOR OR RENEwED:
\ r i /
I
Y ( i /) ( Ln Ke---
issuing license)
I - 'r
LICENSING AUTHORITY:
(name of city, county or state agency
LICENSE REN~~AL DATE:
PERSONAL INFOR"ATION (If applicable):
Aeoi Icant's Name:
Aeel Ican:'s Aoaress:
C I-:y
S-:a:e
Zie eooe
Sc:ial Se:~~ity ~~~~€-:
BUSINESS
INFOR"ATION (If BPPllcaft): .
:::::.., f:!~~iS ~~UJ!/;J:;, ~~:jf~JiJ~
-ff'(Dr LuKt' rnfl 5,GJ'-
City State Zie Cooe
Business
Business
Minnesota Tax loentification No.:
Federal Tax Identification No.:
I
- .. ~
..1,
"
)
jf a Minnesota Tax Jdentification number is not reouireo. Dlease explain
on tne reverse side.
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Signature
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(..,....
l.(,. "~'- r~ -c~-..-)/
Position (Officer. Partner, etc.) Date
LICENSE QUESTIONNAIRE
NAHE OF EST IdL I S~.T -L.J 1:l y1 ~ r PI f) $r.U e .:ft'i) Ij ~r U ,~.sIL e...-
lYPE OF LICENSE 1 ,. .1, ,- ~ . .' ~ i : =:
TYPE OF OWNERSHI P _ 126 (P (Q:!l ~ _
NUMBER OF EMPLOYEES .':
NAMES OF EMPLOYEES
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BIRlli OATES
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NA.P€ OF MANAGER
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NAMES OF OWNERS
~ohn l)..J Ibl.fJJ
:JQrnp~O. L I()~~
flk,rf~ L, U,,(d
Please return to:
City of Prior Lake
4629 Dakota Street SE
P .0. Box 359
Prior Lake, Kfnnesota 55372
. .
....
PROOF OF WORKERS' COMPENSATION INSURANCE COVERAGE
Minnesota Statute Section 176.182 requires every state and local licensing
agency to withhold the issuance or renewal of a license or permit to ooerate a
business ln Minnesota until the aoplicant presents acceptable evidence of
compliance with the workers' compensation insurance coverage requirement of Section
176.181. Subd. 2. The information required is: The name of the insurance company,
the policy number, and dates of coverage or the permit to self-insure. This
information will be collected by the licensing agency and put in their company
file. It will be furnished, upon request, to the Department of labor and Industry
to check for compliance with Minnesota Statute Sec. 176.181. Subd. 2.
This information is required by law, and licenses and permits to operate a
business may not be issued or renewed if it is not provided and/or is falsely
reported. Furthermore, if this information is not provided and/or falsely
reported. it may result in a S1.000 penalty assessed against the applicant by the
Commissioner of the Department lof labor and Industry payable to the Special
Compensation Fund.
Provide the information specified above in the spaces provided. or certify the
precise reason your business is excluded from compliance with the insurance
coverage requirement for workers' compensation.
Insurance Company Name: emf ID~ee..- B/J~f- PJrn, {\1.:s+rf1-{f'DIJ (};.
(NOT the insurance aqent)
Policy Number or Self-Insurance Permit
Dates of Coverage: I/O K jtlf) -j D
.
Number: DLj - D;;)' 74?J1 -3
i/oY I tf/
(or)
I am not required to have workers' compensation liability coverage because:
( I have no employees covered by the law.
( Other (Specify)
I HAVE READ AND UNDERSTAND MY RIGHTS AND OBLIGATIONS WITH
lICENSES, PERMITS AND WORKERS' COMPENSATION COVERAGE,
INFORMATION PROVIDED IS TRUE AND CORRECT.
REGARDS TO BUSINESS
AND I CERTIFY THAT THE
/' ~ // / //; / ./
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/ (SIGNATURE)
JAlle (J) 7/87