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CITY OF PRIOR LAKE
K. _---= pr of lianilltitt - ;11rtsperfitItt --; >l'
' 1Final Permitted ❑ Conditional C.O. Expires
, This Certificate issued pursuant to the requirements of Section 110 of the ❑ Residential I ❑ International
Building Code certifying that at the time of issuance this structure was in compliance with the various
K. ordinances of the City of Prior Lake regulating building construction or use. For the following:
' Use Classification S /N 1.6: F) /1 / 11 Bldg. Permit No / 11 - -- 6. .1
Occupancy Type Type Construction V/V Zoning District /e /`—
Legal Description
Owner of Building Site Address /44/0 e1 ` f L/f) f t-i -k-e:: Et.)6 e '
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Contractor's Name & Address n, / �r1& ct'N' C--• 4-J✓ l v V D /�(/y Gr :J./ 4t /00 . '
7 Eit T HU / t / / / iS. ` City Planner B eI ✓•. 1// /iZ.G
Building Official 'J
Date: ' , (1 Date: 4j.
POST IN CONSPICUOUS PLACE
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PRIp CITY OF PRIOR LAKE BUILDING PERMIT, Date Recd
ov ,, ;� +' TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
�' j AND UTILITY CONNECTION PERMIT 2_7 '
U '-3 g
�NNE SO 1P 1. White File 2. Pink PERMIT NO. 70 , J r c, 5
Qty
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS
ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION - c... A PID
OWNER / �
(Name) i - \ct ,r, 4 MO C l % 'zGa linfil o s (Phone)
(Address)
BUILDER _
(Company Name) A - 1 1 4A'--4& 4 114 (Ali . (Phone) , '''' .. 12 . - 4
(Contact Name) X-} i .4.6, (Phone) ea / 2 - ) 7 7 6
(Address) tL „LA/S. r4 4,, , t /00 takI SV. has AA 44 sc 4 s
TYPE OF WORK ew Construction ❑Deck ❑Porch ❑Re- Roofing ❑Re- Siding ❑Lower Level Finish ❑ Fireplace
k ddition ❑Alteration ❑Utility Connection
CODE:V ❑I.B.C. El Misc.
Type of Mtction: I II III IV V A B (�
Occupancy Group: A B E F H I MR S U PROJECT COST /VALUE $ /
Division: 1 2 3 4 5 (excluding land)
I hereby certify that 1 have furnished information on this application which is to the best (gray knowledge true and correct. I also certify that I am the owner or authorized agent for the
above - mentioned property and that all .. tructio, will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building
official ca r oS.e this permit for} , t c .re, I hereby agree that the city official or a designee may enter upon the property to perform need tions
S Contractor's License No. Date
Permit Valuation 4 o O 000. - s Park Support Fee # $
t
Permit Fee $ SAC # $
z$53 .5o
Plan Check Fee $ ' 8 54-. 1 S Water Meter Siz: ; 1"; $ (, (0 -
State Surcharge $ Z O �. _ Pressure Reducer $ D
Penalty $ Sewer /Water Connection Fee # $
Plumbing Permit Fee $
(S4.50 Water Tower Fee # $
Mechanical Permit Fee $ • 15 . So Builder's Deposit $ ,Ste.
Sewer & Water Permit Fee $ 5(0.c0 Other $
Gas Fireplace Permit Fee $ 54. 5v TOTAL DUE C��� #7 / 9 / $ 7 5215.
This Application Becomes Your Building Permit When Approved Paid ° f 5 a 0. 7j1 ' Re pt No. CQ &.% Z
Date 7 Z O, /o B
Building Official 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 the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy must k
issued. tlty ev
7 — li /O /V• rwrpervAn.s Sivett bierused a/l wei
PI g 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: /h . Date: 7 - g - 11U
Building Permit # PID: Zoning: R15 ,0
Address: 1114 51e v✓•aters eg T.,,;1
Legal: L , B Subdivision: ttoof
Existing Structure? j P NO Existing Nonconforming Structure? YES kp,
CONFORMS TO ZONING YES NO
ORDINANCE
Yard Setbacks: NA 1 FAILS/ COMPLIES 1 Standard Proposed
• Front Yard (can be 20' if avg. wrn 150') 25' .7s.5
• Side Yards 107 .
25' if abutting a street
• Sidewall exceeding 50' requires additional side 2" 10' setback +
setback for every 1' over 50' in length 2 "/1' over 50'
• Rear Yard 25' ti'i'
• Patio Door provide for minimum 10' deck or sign 10' side/
statement indicating no deck will be built in the future 25' rear
• From 100 year flood elevation of wetland/NURP 30' Nrc
pond
• From OHW (Prior or Spring Lake) 75' or setback average of -Cif '
adjacent structures, but no
less than 50'
I Floor Area Ratio: NA 1 FAILS 1 COMPLIES 1 .30 Maximum 1 I
I Yard Encroachments: NA 1 FAILS /COMPLIES Standard 1 Proposed
Eaves and Gutters no more than 2 feet in width and no
closer than 5 feet to a lot line (Easements).
A/C and other equipment cannot encroach on interior
side yards.
I Tree Preservation: NA /FAILS 1 COMPLIES 1 Standard 1 Proposed
• Total tali • er inches ` g
• PermitR5% Removal 6?
• Caliper Inches Removed 6 .9, S ''
• Caliper Inches Preserved / a 9
• Replacement %: N ' 4
0
L: \TEMPLATE\BLDGLIST.DOC Y ' 0
Driveway: NA 1 FAILS 1 COMPLIES Standard Proposed
• Maximum width at property line 24'
• Required setback 5' from side lot line or 3
30' from r-o-w on comer lots
• Maximum slope 10%
• All parking areas to be paved including R -V or
spaces adjacent to the garage
• Location to match subdivision grading plan _
I Building Height: NA / FAILS /COMPLIES 1 35' Maximum 1
Shoreland District: NA 1 FAILS / COMPLIES Standard Proposed
Minimum lot area (square feet) 7,500 Rip, 7,999 Non-rip
Minimum lot width 50' Rip, 57.3' Non -rip
Shoreland alterations
Impervious surface 30% Maximum
Bluff in Shorelan N�f FAILS 1 COMPLIES Standard ' Proposed f
• Setback from top of bluff By planning dept.
• Bluff impact zone 20' From Top of Bluff
• Engineering certification submitted /approved By City Engineer
• Grading in bluff or bluff impact zone No importing /exporting
Floodplain: NA 1 FAILS / COMPLIES Standard Proposed
• 100 year flood elevation 908.9' Prior Lake 90 S'
914.4' Spring Lake
• Lowest floor elevation 909.9' Prior Lake /
915.4' Spring Lake 9°9, 9
• Proposed lowest floor elevation Must be 1' above flood
elevation for new and existing
structures. If existing `rid • 7 &
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 o K
higher
• Road access must be no more than 2 feet below 907.9' for Prior Lake O
Regulatory Flood Protection Elevation 913.4' for Spring Lake
. Accessory Structure(NA)AILS / COMPLIES Standard Proposed
• Size 832 sq.ft. or 25% rear yard
• 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
Q� PRtoe
CITY OF PRIOR LAKE Date Rec'd
- 4' AN ,
DEMOLITION PERMIT , Z .
� /D 9
rNA,Bso
• PERMIT NO./0 , 5- (, c,
• (Please type or print and sign at bottom)
ADDRESS , ZONING (office use)
/ 4-1 s ;\, f® cs.� �. /
LEGAL DESCRIPTION (office use only) .
LOT . BLOCK ADDITION 5 tt c i-" - J L e c c i PID
(Name) R 7 /€ ti A` / -~ (Phone) 9 s 7 yC - f ?7 Y
(Address) /.�. -- 3 L+.., 4 r-- tom -
CONTRACTOR
(Company Name) At 4i i 6 Vi.it.- a. -71 L . (Phone) 9 f L '" FS t '"` n' 4
(Contact Name) 0'9 f t-a 4 .S (Phone) Kra — ? tr.: ° 7? el
(Address) /$3 t c t r - rte.- /( , �.. 1 4 -er( ... 3.'` r
Use of Building: INTERNATIONAL BUILDING CODE
Type of Construction: 1 It III A
5trt&Le 64111LY PwEt..-1. Occupancy Group: A B E F II I M ar> S U
Division: ar 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,
I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
ll
• Signature Date
_ This A • plkation Becomes Your Demolition _ �, t '611 � ' t
� .
1 P -r: When Approved
� , / .D DEPGd/T S 4 ve d. gib 6. 3d • I 0
/ 7 8 /0 eic yr cc .1 ON Vilvt.-7) • 0_,
Building Official 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 u requested.
,././ �� r 7 � /e
Planning • ctor Date Special Conditions, if any
24 hour notice for all Inspections (952) 447 -9850, fax (952) 447 -4245
16200 Eagle Creek Avenue, Prior Lake, Minnesota 55372
oz .4 FRI0
Lt'
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White - Building
�, �� Canary -Engineering
^'NES° Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT A /14/1,5 - 66 '-
APPLICATION RECEIVED ea .. -y'- /O
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
`440 f fl Rf / 7 zU ./�L, .
Accepted z Accepted With Corrections
Denied
Reviewed By: Date: 743/0
Comments: + • Cerra -o� E/Le3Sivv s /11A7Nr.9frO £ c U cri2
kr 4 77 &S.
Z. ,4r Fo�Na4Tt0 (,. w...3 Pt2ov toe. AN Lev/0.ri .,.-3 q 6g., Fic..ATh' ►
L46--r-r64.. FR-0 Wt T14e S.)R.ve o.4 S*.4riA3 co TwarTt -4c' Toe of THe
Foot-'o 4+rb.J, E- Fv-r. Ft..CCIA S.A. t_or4J4 =s Fu 4z002- 't..
(it-) li -c. P, A Bev 6 TH& Re MINirtvM PLo0ti L- G- 1%4.raevooF X 101.9.
3. ?Rog toe. 7 Eel A C ear t Ftc"r Fegt-rt s&r Tt,t Fa '—
IN 4F 13.d-F014-e ocau rttiA TI-Kr BcJ i�d ,,.Jv - Sea 6 c. sto C toy.
"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."
4 P Rlo
o 4
6 White - Building
��NNES��P Pink ry - Planning ing
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED 1
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: �/ C Date: - 7/1 9// 0
Comments: See Attachinents: 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 tot 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 footing
inspection.
G: \Admin \dept info \ADDITIONAL COMMENTS FOR BUILDING PERMIT APPLICATIONS.doc
O� PRip�
e
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U rr1
White - Building
�, �P Canary - Engineering
NNESO Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT /1 //////.._ '.-
APPLICATION RECEIVED `" ' " /IC
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: 1137(4 Date: /9-/a
Comments: Comments: _ -nyler v oa -<�,..r4ee Co %rve / at /h�rimum a�a wed at
4.44-10. /!
GCr c •. e- 0-r/e
Trees nut nuoKeot 61- rer"oved o' survey
!kLtst b save tree t yCkee"
"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."
4 PRI CITY OF PRIOR LAKE Date Rec'd
t 4 HEATING /AIR CONDITIONING /FIREPLACE PERMIT e 4 / 0
g
jMvESO�P 1. Pink File PERMIT NO.
2. Green City
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
I T 4 d 8 t,. ctxrc edge_
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
APPLICANT , 5-2.,. 4 3s 3
(Name) ' L 1/ 7 i�
J6 t / 7 ', N r- (Phone)
(Address) f . O A X30 jt 7 7 1... 24/0/ S ots/
(Address) / (City) (Zip Code)
(Contact Person) &t / f J /` - (Phone) LD/ ' 2 Q " `� ? /3(0 7
APPLICANT SIGNATURE L ( DATE Ay 6 r lb
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION ❑ REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
❑Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
❑Air Conditioning ❑ Special Devices Fireplaces with Box Additions or
[Went. System 0 Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
FIREPLACE MAKE AND MODEL
FEE SCHEDULE
Industrial, Commercial & Multi- Family 1% of job cost Residential, Gas Fireplace $49.50
$49.50 minimum
Residential, Heating & A/C (New Construction) $149.50 Residential, Additions & Alterations $49.50
Residential, Heating Only (New Construction) $64.50 Residential, AC Only $49.50
Estimated Cost $ Building Permit # py 1 'J ^ BY
HEATING PERMIT FEE $
STATE SURCHARGE $ .50 13
TOTAL PERMIT FEE $
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid g A
t No.
Date
B
II IIIIMIII
uildine Official Date E
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 .
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
O .. 2R/0 Date Rec'd
H 9 CITY OF PRIOR LAKE PLUMBING PERMIT
x
jNNEsdo* 1. Blue File
2. cola City PERMIT NO. 0 4
3. Yellow Applicant •
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
144b8 W ATE f $ C &E TPA IL
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
((Na WNER A /fin A p co N 5 v �- Ti N (Phone) 952- 6 q2 - 549
(Address) 1 4.551 JOD1C /ft1 1ao/ID $ )0( OURNS /MZ S
APPLICANT WEN i, p� 6 % / 5/-452- '%
(Name) Z,EL PLY M UvT8 PLO (Phone) 6
(Address) 17/0 4t ex/ Nocz RD 09 5 / Z f
(Address) (City) (Zip Code)
(Contact Person) P ` V E— l U M 4 (Phone) tO 51 " 24-8-4-2:7) • APPLICANT SIGNATURE • ! 4 s-- DATE 0/02. I/o
0 APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
3 Bath Tub with or without shower Rough -ins
1 Dishwasher i Water Heater
t Floor Drain Water Softener
Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
1 Laundry Tray (1 or 2 compartment sink Sewage Ejector
I Shower Stall Backflow Assembly
{ Sinks Backflow Assembly Test
Bar Sink 1 Lawn Sprinkler
g^ Water Closet (Toilet) Other
FEE SCHEDULE
Industrial, Commercial & Multi - family 1% of job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
Residential, Additions & Alterations $49.50
Estimated Cost $ Building Permit # PAID W
PLUMBING PERMIT FEE $ BUILDING PERMIT
STATE SURCHARGE $ 5
TOTAL PERMIT FEE $
(Office Use Only)
This Application Becomes Your Building Permit When Approved I Paid — Receipt
i l o
Date (T S ` B b or
Building Official Date 0 iliiiiii
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
10
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
,„t
•
•
Land Surveyors
Planners
Valley Surveying Co., P.A.
(952) 447 -2570 Suite 230
16670 Franklin Trail S.E.
Prior Lake, Minnesota 55372
August 4th, 2010
Alan Tholkes
14408 Waters Edge Trail NE
Prior Lake, MN 55372
RE: 14408 Waters Edge Trail NE
CERTIFICATION:
I hereby certify that on August 3rd, 2010, I did measure the top of the poured foundation of the
house under construction at 14408 Waters Edge Trail NE, Prior Lake, Minnesota. I further
certify that the elevation of said poured foundation wall is 910.3, NGVD•29 adj.
Scott M. Swanson, PLS
Minnesota License Number 42309
Our file No.10679
443 Lafayette Road N. M I N i!�1 E5C7 TA DEPARTMENT „ (651) 284 -5005
St Paul, Minnesota 55155 j 1-800- DIAL -DLI
www.dli.mn.gov �.�1`�! BOR 84 I N D U T RY TTY: (651) 2974198
10/27/2010
APPROVED FOR USE
Alan & Monaliza Tholkes
14408 Watersedge TrI
PRIOR LAKE, MN 55372
RE: RES INCLINED WHEELCHAIR LIFT Elevator ID# ELV- 1002308
Site: Alan & Monaliza Tholkes
14408 Watersedge TrI
PRIOR LAKE, MN 55372
Dear Sir /Madam:
Minnesota Statutes Chapter 326B provides that the Department of Labor and Industry, Construction Codes &
Licensing Unit, Elevator Safety Section, inspect and approve elevators and manlifts (endless belt lifts) before
they can be legally used in Minnesota. An Inspector from the Elevator Safety Section recently inspected your
facility and determined it meets requirements of the Minnesota Elevator Safety Code.
NOTE: Compliance with Minnesota Rules and the ANSI /ASME A17.1, Safety Code for Elevators and
Escalators does not necessarily assure compliance with the Americans With Disabilities
Act of 1990.
ALL ELEVATOR RELATED EQUIPMENT IS SUBJECT TO ANNUAL RENEWAL OF THE OPERATING
PERMIT: It is the owners responsibility to maintain and keep current with all tests in accordance with the
ASME A17.1 and the ASME A17.3. Frequencies for the required tests can be found in Chapter 1307 of
the Minnesota State Building Code. Failure to maintain and perform the required tests may result in
revocation of the annual operating permit. Operation of an elevator related device without a valid
operating permit may result in an issuance of a "stop order" from the department and possible penalty of
up to $10,000. For more information see our website at: http: / /www.dli.mn.gov /CCLD /Elevator.asp
Sincerely,
CONSTRUCTION CODES & LICENSING
Todd King
State Elevator Inspector
This information can be provided to you in alternative formats (Braille, large print or audio).
An Equal Opportunity Employer
U.S. DEPARTMENT OF HOMELAND SECURITY - FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. NO. 1660
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 rots/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
Q 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 flood.
❑ 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 WI would not be inundated by the base flood 11 511 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 backfiiling with select structural material is not considered the
placement of rill lithe 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 fits been placed on your property to raise
ground that was previously below the BFE? ® Yes ❑ No If yes, when was fill placed? 0712010
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):
14408 Waters Edge Trail NE, Prior Lake, MN 55372
2. Legal description of Property (Lot, Block, Subdivision)(complete description as it appears in the Deed is not necessary):
Lot 22 and p/o Lot 23, BOUDIN'S MANOR, 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 an the property? What are the dates of construction? 2010
4. Is this request for a (check one):
® single structure
n single lot
❑ multiple structures (How many structures are involved in your request? List the number. )
❑ multiple lots (How many lots are involved in your request? List the number. )
DHS - FEMA Form 81 -67, DEC 07 Property Information Form MT -1 Form 1 Page 1 of 2
In addition to this foram (MT -1 Farm 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 assessors 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. It 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:! lwww. fema. govlplan 1preventlfhmlfrm_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)
n $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. t 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: Alan Tholkes Company.
Please Print or Type
Mailing Address: 14408 Waters Edge Trail NE Daytime Telephone No.: 612 -859 -1536
Prior Lake, MN 55372
E -Mail Address: Fax No.:
(optional) "" 1
Date t ^ Signature ofApplfcant (required)
If you have any questions concerning 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:llwww.fema.govlfhm /.
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 Alan Tholkes Policy Number
A2. Building Street Address (including Apt., Unit, Suite, and /or Bldg. No.) or P.O. Route and Box No. Company NAIC Number
14408 Waters Edge Trail NE
City Prior Lake State MN ZIP Code 55372
A3, Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
Lot 22 and Igo Lot 23, BOUDIN'S MANOR, Scott County, Minnesota. (PID #251190190)
A4. Building Use (e.g., Residential, Non - Residential, Addition, Accessory, etc.) Residential
A5. Latitude/Longitude: Lat. 44.4431.1 Long. 93.2309.0 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) sq ft a) Square footage of attached garage 1.011 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 within 1.0 foot above adjacent grade 3
c) Total net area of flood openings in A8.b sq In c) Total net area of flood openings in A9.b 37.152 sq in
d) Engineered flood openings? 0 Yes ❑ No d) Engineered flood openings? 0 Yes ® No
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B1. NFIP Community Name & Community Number B2. County Name 1 83. State
City of Prior Lake, Minnesota 270432 Scott MN
B4. Map/Panel Number 85. 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)
12/20/74 11/19/97 AE 909.0
B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in Item B9.
❑ FIB Profile ® FIRM ❑ Community Determined ❑ Other (Describe)
B11. Indicate elevation datum used for BFE in Item 89: ® 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 Ai A30, AE, AH, A (with BFE), VE, V1 -V30, V (with BFE), AR, AR/A, AR/AE, AR/A1-A30, AR/AH, ARIAO. 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) 910.3 ® feet ❑ meters (Puerto Rico only)
b) Top of the next higher floor 920.8 ® 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) 910.3 ❑ feet ❑ meters (Puerto Rico only)
e) Lowest elevation of machinery or equipment servicing the building 0 feet ❑ meters (Puerto Rico only)
(Describe type of equipment and location in Comments)
f) Lowest adjacent (finished) grade next to building (LAG) 909.4 ® feet ❑ meters (Puerto Rico only)
g) Highest adjacent (finished) grade next to building (HAG) 910.2 ® feet ❑ meters (Puerto Rico only)
h) Lowest adjacent grade at lowest elevation of deck or stairs, including 908.5 ® 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.,
understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1009.®
Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a
licensed land surveyor? ® Yes ❑ No
Certifier's Name Scott M. Swanson License Number 42309
Title President Company Name Valley Surveying Co., PA
Address 16670 Franklin Trail SE City Prior Lake State MN ZIP Code 55372
Signature r Date 11101 /10 Telephone 952 -447 -2570
,-' .lira
gir
For Insurance Company Use:
IMPORTANT: In these spaces, copy the corresponding information from Section A.
Building Street Address (including Apt., Unit, Suite, and /or Bldg. No.) or P.O. Route and Box No. Policy Number
14408 Waters Edge Trail NE
City Prior Lake State MN ZIP Code 55372 . Company NAICN umber
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 newly constructed slab on grade home. Previous Dwelling on subject property had a lowest
floor that was below BFE. It was demolished and fill was placed to construct current dwelling. At the time field data was collected, 10129/10, the elevation of
Prior -jce was 902.3. All el ions on NGVD 29 adj. datum.
igp= u = / Date 11/01/10
r � ( ❑ 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, 8,
and C. For Items El -E4, use natural grade, if available. Check the measurement used. In Puerto Rico only, enter meters.
El. 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 0 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 0 meters ❑ above or 0 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, 8, 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, 8, C (or E),
and G of this Elevation Certificate. Complete the applicable item(s) and sign below. Check the measurement used in Items GB 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. 0 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: 0 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
n Check here if attachments
.Hz, 0 ) 0 E,C) CITY OF PRIOR LAKE
Impervious Surface Calculations
(To be Submitted with Building Permit Application)
For All Properties Located in the Shoreland District (SD).
The Maximum Impervious Surface Coverage Permitted is 30 Percent.
Property Address 1 4 1 1 4 0 l b 4e ; 41 /6. n l '
Lot Area L 4 Z l To 81e.,/ 90 sq. ft. x 30% =
9
***************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
LENGTH WIDTH SQ. FEET
HOUSE x
c x
ATTACHED GARAGE x =
l 16e6 es !� for o 4' 4 TOTAL PRINCIPAL STRUCTURE ?, 777
DETACHED BUILDINGS x
(Garage /Shed) x
TOTAL DETACHED BUILDINGS
DRIVEWAY/PAVED AREAS x =
(Driveway- paved or not) . x
(Sidewalk/Parking Areas) x =
TOTAL PAVED AREAS 78 y
PATIOS/PORCHES/DECKS x =
(Open Decks' 'A" min. opening between X =
boards, with a pervious surface below,
are not considered to be impervious)
X
TOTAL Drt€KeS...':2� &re, 1 .. ' '_
:3 ex)
OTHER x =
x =
TOTAL OTHER
TOTAL IMPERVIOUS SURFACE 4! 8 S `y
UNDE • • VER
Prepared By C4 M. c Orr► Sol...) Date ,'7 /15 /1
Company Ali ,
1/4
t. ' l CO PA. Phone # 75 ' i '/7 S'7 0
L:\HANDOUTS\IMP ERvious.doc
DEPARTMENT OF
P RIOR LAKE BUILDING'AND INSPECTION
INSPECTION RECORD
SITE ADDRESS k co u-' r - Tiz. NI L..
NATURE OF WORK sri4c.v Fite -t %Li 3:).- aE'LLLJCC sac. ®rte nta pe t4
USE OF BUILDING sftp
PERMIT NO. / U, 5(5 DATE ISSUED •
CONTRACTOR A rt AA *$ aotssmtvc.ruorJ PHONE 41 Z •ups -1T80k
NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW
THE PERMIT IS BY SEPARATE DOCUMENT
I" �4 tn4T,a� 1 nt eP.os i „ Ca
".► 11 4 I oata O S A' pT "'t."
1 FOOTING,,r , , 4, -D40 , ;' 1 g 1 8/4
FOUNDATION (Prior to Backfill)4et.EV- rto vetztt✓l r -N 8 CO QC ' O 1 7
PLACE NO CONCRETE UNTIL. ABOVE HAS BEE» S
Re">. a
& y+1 ST c3, $ c -hR G 9 1 N r 5°-'116 �' «645
SEWER / WATER / SEPTIC
FRAMING `"I(',
INSULATION fl4
ELECTRICAL
PLUMBING r 6 �? to 10 1 i
HEATING (if required) `
FIREPLACE PM Q
GAS LINE AIR TEST ntkM,, . tA . q f q�b �{�• , $ar,�a, j2, i %,)3J;r9
ps p1.1 s s re'
COVER NO WORK UNTIL ABOVE AS BEEN SIGNED
1 1 4cos4-1.44204P LTNe 1 ,4! * J/ rn 1
FINALS
GRADING (Prior to Sodding) illy, c �
BUILDING FertA -... h ` + SPin
ELECTRICAL
PLUMBING,ro 46 6 ww % s 5L,,,„1, 7; 14,,,,j/
HEATING
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