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Permits - Permit# 3-24-17 - 2494 Black Lake Road - 1/1/2017WATER RESOURCE PERMIT APPLICATION FORM Use this form to notify/apply to the Minnehaha Creek Watershed District (MCWD) of a proposed project or work which may fall within their jurisdiction. Fill out this form completely and submit with your site plan, maps, etc. to the MCWD at: 15320 Minnetonka Blvd. Minnetonka, MN 55345. Keep a copy for your records. YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. 1. Name of each property owner: James Paul Mailing Address: 14 82-7- 1 ! M r?t e 1 ea/L l'd tA_J City: p l'� f. L e" State: /i /✓ Zip: Email Address: jim_paulCavalleycardealers.com Phone: a / 2 Z7S--312?, Fax: 2. Property Owner Representative Information (not required) (licensed contractor, architect, engineer, etc...) Business Name: Stonewood, LLC Representative Name: Nate Mitchell Business Address: 153 Lake St E City: Wayzata State: MN Zip: 55391 Email Address: nate@stonewood.com Phone: 612-251-9713 Fax: 3. Project Address: 2494 Black Lake Road City: Spring Park State: MN Zip: 55384 Qtr Section(s): Section(s): Township(s): Range(s): Lot: 5&6 Block: Subdivision: Skarp&Lindquists Rose Hill pID: 19-117-23-12-0023 4. Size of project parcel (square feet or acres): 27799 sq ft Area of disturbance (square feet): 6000 Volume of excavation/fill (cubic yards): Area of existing impervious surface: Area of proposed impervious surface: 5963 Length of shoreline affected (feet): 0 Waterbody (& bay if applicable): Black Lake/Lake Minnetonka 5. Type of permit being applied for (Check all that apply): * EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES ❑ FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMENT ❑ WETLAND PROTECTION ❑ APPROPRIATIONS ❑ DREDGING ❑ ILLICIT DISCHARGE ❑ SHORELINE/STREAMBANK STABILIZATION 6. Project purpose (Check all that apply): El SINGLE FAMILY HOME ❑ MULTIFAMILY RESIDENTIAL (apartments) ❑ ROAD CONSTRUCTION ❑ COMMERCIAL or INSTITUTIONAL ❑ UTILITIES ❑ SUBDIVISIONS (include number of lots) ❑ DREDGING ❑ LANDSCAPING (pools, berms, etc.) O SHORELINE/STREAMBANK STABILIZATION ❑ OTHER (DESCRIBE): 7. NPDES/SDS General Stonmwater Permit Number (if applicable): 8. Waterbody receiving runoff from site: Black Lake/Lake Minnetonka 9. Project Timeline: Start Date: 4.10.17 Completion Date: 1.15.18 Permits have been applied for: City ® County Q MN Pollution Control Agency 0 DNR 13 COE Permits have been received: City � County � MN Pollution Control Agency DNR­—Q COE—M By signing below, I hereby request a permit to authorize the activities described herein. 1 certify that I am familiar with MCWD Rules and that the proposed activity will be conducted in compliance with these Rules. I am familiar with the information contained in this application and, to the best of my knowledge and belief, all information is true, complete and accurate. I understand that proceeding with work before all required authorizations are obtained may be subject to federal, state and/or local administrative, civil and/or criminal penalties. Signature of Each Property Owner Date Devised 7/ 15/ 13 Page 1 of 1 Poor Quality Document Disclaimer The original or copy of a document or page of a document presented at the time of digital scanning contained within this digital file may be of substandard quality for viewing, printing or faxing needs. WATER RESOURCE PERMIT APPLICATION FORM Use this form to notify/apply to the Minnehaha Creek Watershed District (MCWD) of a proposed project or work which may fall within their jurisdiction. Fill out this form completely and submit with your site plan, maps, etc. to the MCWD at: 15320 Minnetonka Blvd. Minnetonka, MN 55345. Keep a copy for your records. YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. 1. Name of each property owner: James Paul Mailing Address: 14 82--�i M Ri e w.;�� /`J �� City: Pe«� L State: /iZip: Email Address: lim Paul@valleycardealers.com Phone: a/;� Z?S--2�� Fax: 2. Property Owner Representative Information (not required) (licensed contractor, architect, engineer, etc...) Business Name: Stonewood, LLC Representative Name: Nate Mitchell Business Address: 153 Lake St E City: Wayzata State: MN Zip: 55391 Email Address: nate@stonewood.com Phone: 612-251-9713 Fax: 3. Project Address: 2494 Black Lake Road City: Spring Park State: MN Zip: 55384 Qtr Section(s): Section(s): Township(s): Range(s): Lot: 5&6 Block: Subdivision: Skarp&Lindquists Rose Hill pID: 19-117-23-12-0023 4. Size of project parcel (square feet or acres): 27799 sq ft Area of disturbance (square feet): 6000 Volume of excavation/fill (cubic yards): Area of existing impervious surface: Area of proposed impervious surface: 5963 Length of shoreline affected (feet): 0 Waterbody (& bay if applicable): Black Lake/Lake Minnetonka 5. Type of permit being applied for (Check all that apply): O EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES ❑ FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMENT ❑ WETLAND PROTECTION ❑ APPROPRIATIONS ❑ DREDGING ❑ ILLICIT DISCHARGE ❑ SHORELINE/STREAMBANK STABILIZATION 6. Project purpose (Check all that apply): © SINGLE FAMILY HOME ❑ MULTI FAMILY RESIDENTIAL (apartments) ❑ ROAD CONSTRUCTION ❑ COMMERCIAL or INSTITUTIONAL ❑ UTILITIES ❑ SUBDIVISIONS (include number of lots) ❑ DREDGING ❑ LANDSCAPING (pools, berms, etc.) ❑ SHORELINE/STREAMBANK STABILIZATION ❑ OTHER (DESCRIBE): 7. NPDES/SDS General Stormwater Permit Number (if applicable): 8. Waterbody receiving runoff from site:Black Lake/Lake Minnetonka 9. Project Timeline: Start Date: 4.10.17 Completion Date: 1.15.18 Permits have been applied for: City E3 County 13 MN Pollution Control Agency © DNR 13 COE El Permits have been received: City County MN Pollution Control Agency DNR—® COE--0 By signing below, I hereby request a permit to authorize the activities described herein. I certify that I am familiar with MCWD Rules and that the proposed activity will be conducted in compliance with these Rules. I am familiar with the information contained in this application and, to the best of my knowledge and belief, all information is true, complete and accurate. I understand that proceeding with work before all required authorizations are obtained may be subject to federal, state and/or local administrative, civil and/or criminal penalties. Signature of Each Property Owner Date Revised 7/15/13 Page I of l EROSION CONTROL SUPPLEMENTAL INFORMATION FORM INSPECTION PLAN REQUIREMENTS 1. Routine Inspections: • Once every seven days during active construction • Within 24 hours of a half inch or more precipitation 2. Completed Field Inspection Reports: Reports available within 24 hours of request until MCWD determines project is complete & stabilized . Failure to submit requested inspection information will result in a site inspection and may be subject to reimbursement for MCWD staff time. Who will inspect your site regularly? NAME: bJ Lrt N. LLL Et �^` ti ORGANIZATION: tiJn' oor, PHONE: G i 2 - Z5 I - l ALTERNATE PHONE: r Z - 4G 2 - 400 EMAIL: n) a e (-DJ f. wao Where is the concrete washout location? 11 OFF SITE OR CONTAINED ON TRUCK ❑ INDICATED ON SITE PLAN (with required impermeable liner) ❑ N/A What is the final stabilization method? (seed, sod, etc.): 5 p 6 inches of topsoil must be added/replaced prior to final stabilization Will protective fencing for retained vegetation. be installed? YES ❑ NOT APPLICABLE ❑ OTHER (describe) I certify that I am familiar with the u' ments of the MCWD Erosion Control Rule and that the proposed Activity will conducted i c mpliance with this rule. 11(91�— 3. °r Signature of Applicant or Anthori ent Date MINNEHAHA CREEK WATERSHED DISTRICT QUALITY OF WATER, QUALITY OF LIFE I'UM U1I I UNE UINLY Date Received: Permit # ❑ In -House SAC Determination Form Completed Nti MFD,� On Lake Minnetonka 4349 Warren Ave Spring Park, MN 55384 952-471-9051 Approved By (If Required) - Remarks: CITY OF SPRING PARK — SEWER & WATER / GENERAL PERMIT (* Note: Some permits may require approval by the Building Official and/or Public Works Department *) (ALL PERMITS - May be subject to further review and may not be issued when the application is received) GENERAL INFORMATION :. 1. You may apply for utility permits by mail or in person at the City offices. 2. Mailed in applications are subject to the postage and handling fee shown below. Permit cards will be sent by return mail within 2 business days. 3. Permits are not valid until you receive a permit card. 4. Work must not begin unless the permit card is available on the job site. 5. Utility connection permits may be issued to licensed contractors only. 6. Contact the Public Works Department (952471-9051) for utility stub as -built locations. DO NOT EXCAVATE IN ANY STREET AND DO NOT TAP ANY MAIN without express approval of the Public Works Department. Issuance of a permit does not grant this approval. 7. All work must be done in accordance with State Code requirements. 8. All work must be inspected before it is covered. Call (952) 471-9051, 24+hour notice required. Residential (May Require Approval) ❑ Commercial (Approval Required) LJ Industrial (Approval Required) ❑ New Connection ❑ Additional Connection [(Re -Connection ❑ Repairs [Disconnect ❑ Water Availability Connection for Future Hook -Up to Water Job Site / Owner Information; Site Address: 2-514 T5t kr- t:. Owner: n^ E S -PAL.- Mailing Address: 14 $27 (, -kf X"'-fTP-fl,t_ NQ City: 7 ?-t v ?_. �-,,,%=-E- Zip: Home Phone: G 1 2-' 1 `" L- Alternate Phone: Contractor Information: Contractor: 1,1, G Contact Person: Address: 1 53 L A-wf- 5 7 - e State License #: City: �,,, r v Amp Zip: 53 l Expiration Date s t3'-7 Z Ai /?-'rt; to I T%_ 13C5943 is 3 3, ►6 Phone: -Z ' A 61-- 4 acO Alternate Phone: 1 macintosh hd:users.j asonphillips:downloads: spring park sewer & water permit.docx DETERMINING PERMIT FEES ❑ SAC Charge (2016 Rate = $2,485.00) $ (SAC Charge must accompany all sewer permit applications unless prepaid) (Spring Park City Staff can determine if applicable) (If not prepaid, a sewer connection permit will not be issued) ❑ Sewer Connection / Disconnect / Repair ($50.00/Per Stub) $ Pipe size inches; material Schd 40 air tested; ❑ Water Connection / Disconnect / Repair ($50.00/Per Stub) $ Pipe size inches; material air tested; copper ❑ Water Availability For Future Hook -Up to Water ($50.00) $ Water Availability Explanation: Contractor installed line to inside of house for future hook-up. This line will be inspected by the Public Works Department. Required Before Water Connection Permit is Issued: 1. Issue Water Meter & Horn Permit 2. Any Additional Connection Fees Paid (If Applicable) Issue Water Connection Permit: 1. Collect Permit Fee & Issue Water Connection Permit 1. SUBTOTAL of Permit Requested: $ 2. STATE SURCHARGE 1.00 POSTAGE & HANDLING (Only on Mail -In Applications) $ 2.00 4. TOTAL PERMIT FEE (Add Lines 1-3 Above) $ ADDITIONAL INFORMATION — WATER METERS ■ WATER METERS must be picked up and paid for at Spring Park City Hall, these are on a separate permit. ■ WATER METERS must be set and sealed by Spring Park Water Department (952) 471-9051, upon completion of meter installation. The undersigned hereby applies to the City of Spring Park for issuance of a Utility Permit, agrees to do all work in strict accordance with the ordinances of the City and the regulations of the State of Minnesota, and certifies that all statements made on this application are, true and correct. Applicant: Irs, Date: Revised: 4/2 20 SEWER & WATER PERMIT 2 macintosh hd:users:jasonphillips:downloads:spring park sewer & water permit.docx IN HOUSE FORM - TO HELP DETERMINE SAC UNITS to Completed:; # Of SAC Units 'Completed By s 'Y «SAC Previously Paid1"� r." ° Permit #� �� �Date'of Pemit * Char`ge.l%SAC Unit Pei�Home 77 > * If Multiple Homes Or Units May Need TmPay Add>itional SAC Charges *SAC Grandfathered In, Permit # D ate ` of Permit } *>Must have'.had,Hook Up & Home.Pnor To;January,1,1973K to =Refer Helpf d'Hint SheetsOr Ask If Necessary *,If Multiple Units- May•Ne4lo Pay Addi_iional SAC Charges `•Commercial Permit #Accounted For 4 Date of Permit' �(] *Letter From Met Council Showing Use = Or Addrt!onal?Umts Needed y } * Contact Met Council at 651.6 2 1421 To Obtain Letter' , r ."Copies To DJ; Street File '&IOne,On Copy Of,Pei•mitrFogReporting r �', :''Ifa'unable to determme will�have to wait;to be�issued untitdetenninahon can be made k 2 Y PennNeeds Approval,From!PublWWorks : Appioved By.,, v �` ; �'J 1 V:{ ¢ L 1 •i° 'J •:W 3, 1. S • -•' . 3 macintosh hd:users:jasonphillips:downloads: spring park sewer & water permit.docx Construction Staging Plan and Narrative: 2494 Black Lake, Spring Park Completed by Nate Mitchell, Stonewood, LLC, May 8, 2017 1. Parking of workers: no on -street parking on Black Lake Road will be allowed. We will park on Shoreline Dr or at Spring Park City Offices at 4349 Warren Ave. Thank you Spring Park for this offer to help facilitate our project 2. Location for the staging of equipment, materials is designated on the survey attached 3. Material Deliveries will be scheduled in the morning after rush hour and later afternoons before rush hour 4. We will require subcontractor vehicles to safely and properly navigate Black Lake Road with the limited space and immediacy to the neighboring homes and structures and with limited space to turn a vehicle around. Being the end property should provide us advantages of being able to turn around on our property S. Location of dumpsters, Biffs and other accessory items have been noted on the survey /,Wk 6tii s L5.1:�- ,4�� vim® INSURANCE BINDER THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS Sh AGENCY COMPANY Christensen Group Insurance United Fire 6 Casualty 11100 Bren Road West I I EFFEcrne Minnetonka CODE: AGENCY CUSTOMER ID: 00045741 INSURED AND MAILING ADDRESS STONEWOOD LLC 153 Lake Street East I DATE (MMIDDNYYY) 11/l/2016 ON PAGE 2 OF THIS FORM. BINDER # B1611126420 X AM X 12:01 AM MN 55343 11/7/2016 12:01 PM 12/19/2016 NOON 00 1 FAX o ; 952 653-1100 THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY SUB CODE: PER EXPIRING POLICY #: 6 0 4 5 414 3 DESCRIPTION OF OPERATIONS/ VEHICLES / PROPERTY pnduding Locatlon) Loc# 00001 153 Lake Street East Wayzata, MN 55391 (Wayzata I MN 55391 CC)VFRArFR TYPEOFINSURANCE PROPERTY CAUSES OF LOSS BASIC BROAD 1K SPEC COVERAGE/FORMS Backup - Sewers and Drains, Special form Building, Special form Business income/EE-Inc Loss Rents, Special form Business Personal Property, Special form Each Occurrence, $1,000 DEDUCTIBLE 1,000 1,000 1,000 EACH OCCURRENCE LIMITS COINS% 90 90 AMOUNT 50,000 1,068,000 200,000 216,400 $ 1,000,000 GENERALLIABILITY X COMMERCIAL GENERAL LIABILITY DAMAGE T CLAIMS MADE X OCCUR RENTED PREMISES $ 100 000 MED EXP Any one person) $ 5.000 PERSONAL 8 ADV INJURY $ 1 000 000 GENERAL AGGREGATE $ 2,000,000 VEHICLE LIABILITY X ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS Combined RETRDATE FOR CLAIMS MADE: ined single limit PRODUCTS - COMP/OP AGG COMBINED SINGLE LIMIT $ 2,000,000 $ 1,000,000 BODILY INJURY Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ HIRED AUTOS MEDICAL PAYMENTS $ NON -OWNED AUTOS PIP -Basic PERSONAL INJURY PROT $ Uninsured motorist Combined single limit 2012 Dodge/Ram 1C6RD7LTOCS342042 ALL VEHICLES Lj SCHEDULED VEHICLES UNINSURED MOTORIST $ 1 000 000 VEHICLE PNYSICALDAMAGE DED X COLLISION: 500 Underinsured ACTUAL CASH VALUE $ 1.000.000 STATED AMOUNT X OTHER THAN COL: 500 $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN AUTO ONLY: EACHACCIDENT $ AGGREGATE EACH OCCURRENCE $ $ 2,000,000 EXCESS LIABILITY X UMBRELLA FORM Umbrella(C) AGGREGATE $ OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: SELF -INSURED RETENTION $ WORKER'S COMPENSATION PER STATUTE E.L. EACH ACCIDENT $ AND EMPLOYER'S LIABILITY E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ SPECIAL CONDITIONS / OTHER COVERAGES FEES TAXES $ $ NAME &ADDRESS ESTIMATED TOTAL PREMIUM $ MORTGAGEE ADDITIONAL INSURED LOSS PAYEE LOAN #: AUTHORIZED REPRESENTATIVE Brandon Perkins/BARBM �— • .V� • -r v 1 v7.Y4V 13 AL UFIU L:UKFUMATION. All rights reserved. ACORD 75 (2013/09) The ACORD name and logo are registered marks of ACORD INS075 (201309) RESIDENTIAL BUILDING PERMIT SUBMISSION Check In ff V tostamp application rify that this is/should be a residential project ter information in Residential In book — assign number Is a contractor doing the work? IF Yes — verify contractor's license and print verification (https://secure.doli.state.mn.us/lookup/licensing.aspx) ❑ Was structure built prior to 1978 and disturbing >_6 sq. ft. of interior paint or >_ 20 sq. feet of exterior paint? IF Yes —verify contractor is Lead Certified, and print certification page: httPs:Hcfpub.epa.gov/flpp/pub/index.cfm?do=main.firmSearch Q Create Comment Sheet roject number from Residential in Book goes in upper right corner [� Punicipality ermit number (if assigned by municipality) ❑ NAT # (if applicable) Applicant name Site address Kroject description Valuation Is SEC an issue? Is Septic an issue? U Pwner permission needed? (Not applicable for residential projects) FyEnter date received in the first column of the table Q Type "Received application and plans/scope of work/any supplemental worksheets" in second column Type your initials in last column Print Comment sheet, stamp with "Municipality File Copy" stamp, then add any comments of your actions (i.e., "requested 2Id set of plans/SEC worksheet/deck supplemental worksheet by phone/fax/email," or "called septic inspector — application for septic approved," or "emailed township to confirm their approval") Prepare file (green, legal hanging folders) Yellow tab — new home R16-123 John Doe Clear tab —anything else 1234 Main Street, Municipality Line 1: Project # and Applicant or business name 09/20/2016 Deck ❑- Line 2: Site address and Municipality n Line 3: Date received at MNSPECT and Type of project (new construction, addition �ile in back for Pre -Plan Reviewer Pre -Plan Review Verify Application is complete: ❑ Site Address ❑ Owner name, address ❑ Owner Phone number ❑ Contractor name, phone number ❑ Valuation ❑ Approved by municipality ❑ Scope of work indicated (commercial, residential, ag) ❑ Type of work checked (new construction, addition, remodel, etc. ❑ Detailed Description of work to be performed ❑ Signed and Dated ❑ Is signature: owner, contractor, architect, other Supplemental form included and complete: ❑ Accessory Structure ❑ Basement Finish ❑ Deck ❑ Demo (Structure) ❑ Demo (Interior) ❑ Garage(Detached) ❑ New Home ❑ Mobile Home ❑ Modular Home ❑ Porch ❑ Sheds ❑ N/A —none of the above ❑ DOES project require engineered plans? If in doubt, ask Plans Examiner ❑ Approved by municipality (if it requires zoning approval)? ❑ Two sets of COMPLETE AND LEGIBLE plans received? (request if not) ❑ Homeowner's Affidavit included if homeowner is doing work ❑ If this is a Litchfield project, forward to Hannah if it requires zoning approval. SEC Form: ❑ Not disturbing soil ❑ Disturbing soil (new construction, addition, garage, egress window, etc.) — form should be submitted if application is from Bayport, Glencoe, Hamburg, Lakeland, Lakeland Shores, Lester Prairie, Spring Park, or Stewart. Septic: ❑ Checked whether septic is an issue (new homes or additions that include additional bedrooms in HC, CR, WF, DT, GV ❑ File in residential drawer by received date (NOT by project number!) Do NOT put it in the on hold section, even if you have requested information from the applicant —the Plans Examiner will do that when he looks at it. Date Plan Review Completed: Permit order: ❑ Comment Sheet o Communication fields complete o Inspector Issued name field o Date Issued field complete complete o Number of Days total calculated ❑ Application o Occ Type; Const type; Code; o Fees calculated (including license Building Sprinkled info complete look up and copies) o Valuation calculated o Signed/dated by Plans Examiner ❑ Valuation Schedule o Mound Only ❑ Misc. Municipal docs ❑ Permit Card o Project Site Address o Owner/Contractor Name o Date o Required Inspections marked o Description of Work ❑ Site Plans Signed/dated Red sheets available for: o Permit Number if available o Decks ❑ Municipal Plans Signed/dated o Basement Finish o Permit Number if available o Demos o Contractor/Lead verifications o Interior Draintile attached 0 Plastic Bag Date Permit Checked Out: ❑ Permit Fees double-checked ❑ Permit info entered in Permit book ❑ SEC checkbox marked, line colored (if applicable) ❑ If there is a site inspection, staple the appropriate reminder to the front of the site inspection checklist. ❑ Make sure the plans examiner has filled in the rest of the Comment Sheet (Date, initials, number of days). ❑ Add "Permit issued" or "Returned to City" (for Mound), the date, and your initials, to the comment sheet. ❑ Assigned Permit Number on: o Permit Card o Site Plan o Application o Municipal Plan o Comment Sheet ❑ Job moved from Res In book to Res Out book ❑ Mound Valuation Scheduled copied and placed in Nick's folder ❑ CO for new home o Return with Packet: Mound, Glencoe, LP, SL, o Save in L drive until project is finalized: all down south, Plato, Spring Park, Stewart, Hamburg, LL, and LS Bayport ❑ Comment sheet, building permit, permit card ❑ Comment sheet, building permit, permit card scanned to BB — scanned to Comment Sheet Folder on L drive All down south, Mound, Bayport, LSCB, New Hope ❑ Blue "Notice," Comment Sheet, Application, Permit Card, CO (if applicable), Valuation Sheet (Mound only), Misc. municipal docs, Site Plan, Municipal Plan all in plastic bag. ❑ IF LITCHFIELD, COPY THE COMMENT SHEET AND PLACE IN TRACY'S FOLDER ❑ Place in appropriate Municipality bin ❑ Schedule delivery