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Home My WebLink AboutExcavating & Grading Permit 14-G-23 "EXHIBIT A" // o4'�.ruPcj'R, r1 FOR CITY USE ONLY ��arrhha5e��'� PERMIT# /11-6.-23 DATE EXCAVATING & GRADING PERMIT Applicant: �CC`JGLy ` ti i_ -/ (SeGC /ff /J Phone: t% )936- 77 7 Project/Development Name if Applicable: (�L-/ //73 -C-v) Address: / �f z a .C'-4 9 Property Owner: —PO') /1( � / . .1r-) Phone:( /i766 Address: /(1-3/ U062.6t/ -E' Contractor: Z-4, _3/the/4( I--ailaS 61/7//"/c" Phone: Oa 9 ' '7 Address: 1l 61/ ,614' - k'f) Z c'.e--/ %%Xq 676—,.:? Consultant Engineer/Surveyor: 10 a1 ,C/dcal4e�,r`'C" one: `47 Address: / 70 A LL /4") 1. . / / C.0 Emergency Contact(24 HR): L y , ha* Pt Phone: 6 f)) 3 Location of the Property: / Legal Description: Will the excavation or filling be in a: Waterc urse Wetland Upland, K Purpose for the proposed excav ing or filling: /€42_, 6U 11CC�C �` ��= �! ;' ll), -/ ' Estimated start date: 'LL -G.e— 1/2-e--_: )/y/Completion date: What is the type of material to be removed or deposited? L''ci`e / C C '� 4,2-‘24-77 What is the quantity of material to be removed or deposited? c,b/? tif— 5. What is the total area disturbed for excavation or filling? y" p,"c=k t/ice !f�j 3C�C In what manner will the material be removed and/or deposited? •"it What highway, street or other public-way will material for removal or deposition be hauled or carried?/ [.(//3, /116) 1 , What, if any, street,avenue, lane,alley, highway, right-of-way,thoroughfare or public ground will be obstructed? /1 c1i(- _ 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 r s "EXHIBIT A" SUBMISSION REQUIREMENTS: ttk• A. Completed application form *4n B. ap or plat of the proposed filling or excavating showing location and amount of material proposed to be 1),6441 removed or deposited,with a description of the area The depth or heights to which such removal or deposition is proposed throughout the area and the propose. x angle of all slopes to be shown on a 2' contour map at a scale of 1"=50' or larger. The proposed and origina contours shall be shown including all property within 200' of proposed excavation or deposition and shell b: signed by an engineer or surveyor registered in the State of Minnesota ILD. Erosion control plan licN yA,.E. Effect on existing utilities F. Application fee 1,'/GCS . Amount of Letter of Credit, or deposit of monies in a sum sufficient to pay the cost of restoring a site. The extr. ordinary costs of repairing, highways, streets or other public ways along designated routes of travel and to pa such expenses as the City may incur by reason of doing anything required to be done s"' H. Public liability insurance CONDITIONS OF APPROVAL: A. Applicant must call the Engineering Department for erosion control inspection at (952) 447-9830 prior to eart moving activities. B. Maximum 4:1 slopes are allowed in "maintained" areas except approved by City Engineer. Maximum 3:1 slope. 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 pa of a preliminary plat application. F. Applicant is responsible for obtaining and meeting the conditions outlined by other permitting agencies includin: but not limited to the following: DNR,Corps of Engineer,Prior Lake/Spring Lake Watershed District,Scott Count , Mn/DOT, MPCA. G. Applicant is responsible for all damages to other property or facilities as a result of work covered by this permit. H. Applicant must call the Engineering Department for final grading inspection at(952)447-9830 prior to release if grading security. I. Additional Conditions: THE UNDERSIGNED HEREIN CERTIFY THAT THEY HAVE READ SECTION 706 OF THE CITY CODE AND ACCEPT THE TERMS AN CONDITIONS TO THE ISSUANCE OF THIS PERMIT AND AGREE TO FULLY COMPLY THEREWITH TO THE SATISFACTION •F THE CITY OF PRI II LAKE►' INE NG DEPARTMENT QR ITS DESIGNATED AGENT. Applicant: �/ V� Date /-2/E//( � / Property Owner: Date �'\)�1 4 Y "EXHIBIT A" VIREININal ,..wwwx,• ,r, spa»...eauxs a»»*.nve urw,uatire.ere..a mwsaxsas..ws axu. ae Mt+fiv uae.,.,nusua,a;u ra»;.x. n.xa.. ^c„ms „�«. „r,u+..rM, .a,,�r cx t ,uur„,.. IMPORTANT BEFORE STARTING WORK EXCAVATOR AND OPERATOR'S NOTICE This notice is to inform excavators and operators they must comply with Sections 216D.03 to 216D.07 of MINNESOTA STATUTES Call Gopher State One Call (800) 252-1166 or 651-454-0002 Or go to www.gopherstateonecall.org Smart Phone: http://mnticketentrv.korterraweb.com FOR CITY USE ONLY AUTHORIZATION OF PERMIT Financial Guarantee Amount$ Financial Guarantee Type $ 100.0 (Letter of Credit, Bond or Cash) Permit Fee Liability Insurance provided? k Yes 0 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. �/ ENGINEERING OFFICIAL___,4Date /2 -171--/y Permit is valid if signed by City Official PERMIT EXPIRATION DATE from days 90 approval3 -Y-1y( Ydate) Planning Dept. Initials 11\ktk AC RC' De CERTIFICATE OF LIABILITY INSURANCE DATE(M""DOWY""' �... 12/03/2014 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(les)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 NACAMACT Lynda Stoddard PHONE McKee&Andrews Insurance Agency,Inc. ( Ne.Ex* (763)231-3340 ,Ne);(763)2314344 _ 15600 35th Ave N. Suite 202 ADDARILESS; Lyndasemckeeandrews.com Plymouth,MN 55447 INSURERS)AFFORDING COVERAGE NAIC• INSURER A: Owners Insurance Company 32700 INSURED INSURER B: Auto-Owners Insurance 18988 L&R Suburban Landscaping Inc. INSURERC: Auto-Owners Insurance 11421 W 47th St INSURER D: Minnetonka,MN 55343-8889 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 00001785-1231913 REVISION NUMBER: 19 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 ADDL SUBR POUCY EFF POLICY EXP LTR TYPE OF INSURANCE )NSR pVD POLICY NUMBER IMMIDDIYYYYI (MMIDDIYYYY) UNITS A GENERALUABIUTY Y 08010970 01/01/2014 01/01/2015 EACH OCCURRENCE $ 50,000 TO RENTED X COMMERCIAL GENERAL LIABILITY PPR MISES (Ea occurrence) $ 2,000,0(10' CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,0(10 GENERAL AGGREGATE $ I,000,0(IO GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,0(10 POLICY $ LOC PRO- JECT B AUTOMOBILE UABIUTY 9540298300 01/01/2014 01/01/2015 ( &ccideMCOMGLEUMIT 500,0(10 ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS X AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS (Per accident) B X UMBRELLA UAB X OCCUR 9540298301 01/01/2014 01/01/2015 EACH OCCURRENCE $ 2,000,000 EXCESS UAEI CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ `. WORKERS COMPENSATION08039966 01/01/2014 01/01/2015 X TORY uTs Wr STATU- ¶I AND EMPLOYERS'LIVABILITY YIN❑ yllER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) EL DISEASE-EA EMPLOYEE$ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) City of Prior Lake Is listed as Additional Insured as thier interest may apprear CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Ron Ellingson ACCORDANCE WITH THE POLICY PROVISIONS. 14316 Watersedge Trail NE Prior Lake,MN 55372 AUTHORIZED REPRESENTATIVE IF � tc1' (LLa)._ @- 1988-2010 ACORD CORPORATION. MI rights reserwrd. ACORD 25(2010/05) The ACORD name and logo are reegiste • rks of ACORD Printed by LLS on December 03,2014 at 01:52PM