2855 Eagandale Blvd - Workmans Comp LiabilityOFFICE USE ONLY
BUILDING PERMIT SUBTYPE
? 01 Foundation ? 26 Public Facility ? 30 Accessory Bldg.
? 14 Apartments ?27 Commercial/lndustrial ? 32 Ext Alt - Apts.
? 15 Lodging O 28 Greenhouse ? 34 Ext Ait - Comm.
? 25 Miscellaneous ? 29 Antennae ? 35 Ext Alt - PF
WORK TYPE
? 31 New ? 34 Repair ? 37 Demolish Bldg. ? 43 Reroof
? 32 Addition ? 35 Tenant Impr ? 38 Demolish (Interior) ? 44 Siding
33
)< Alterations ? 36 Move Bldg. 0 42 Demolish (Found) ? 45 Fire Repair
, ? 46 Windows/Doors
GENERAL INFORMA.?2
Census Code
SF,C Ccds
No. of Units v
No. of Bldgs.
Const. (Actual) r?
(Allowable) "[?•.
UBCOccupancy 63
Zoning
* ufi S'[ories
Length
Width
Basement sq. ft.
First Floor sq. ft.
sq. ft.
MISCELLANEOUS INSPECTIONS
? Gas Service Test ? Heating
APPROVALS
Planning Building ?
Z- I
I
sq.ft.
sq. ft.
sq. ft.
sq.ft.
MC/ES System
City Water
Fire Sprinklered
?
? Insulation ? Plumbing ? Stucco/5tone
Engineering Variance
cr2.
VALUATION:$ eO /5o)G
Permit Fee
Surcharge
Plan Review
MC/ES SAC
City SAC
Water Supply 8 Storage
S/W Permit
S/W Surcharge
Treatment Plant
Park Dedication
Trails Dedication
Water Quality
Other
Copies
% SAC
SAC Units
Meter Size
4 ;
Total
L.l?•?? R???4?.CE?l?' 1 zS?S`c????lUd ?
CERTIFiCATE OF INSURANCE - WORKMEN'S COMPENSATION & LIABILI'iY ONLY
This certifitate is nsued as a mattcr nl inlonnalion only dnd c(infCrs nt) riyhcs upon the certificate holder. This certificate doesnotamend,
ex[end or alter [he coveraye afforded 6y the policies listecl below.
Project
Owner
iott Auto Supply
5 Pilot Knob Road
ation Eagandale Slvd., Eagan, Mn.
Mn.
Architect/Engineer
??ru v.v __ Address?yuu aerxes evenue nou[n,npls.,mn.»4
Agent COBB ST???13, DU;IPHY A.9ll ZIPMEILMANN Address 400 Builders Exchange, Mpls. Mn.554
WORKMEN'S COMPENSATION:
PolicY- No t?C_6 ?+??r? Effective 7-1-80 Expiration 7-1-81
Insurance Company CONTINENTAL CASUALTY COMYANY Address CHICAGO, ILLI\OIS
Coverage - Workmen's Compensation, Statutory. Employer's Liabili ty Limit $ 100, 000. each accident
PUBLIC LIABILITY:
Policy No. Cf.P 74375Fi$ Eftective 7-1-80 Expiration 7-1-81
Insura^ceCompany-Cf&'Sj.,yF?:1?±T ('dSi!A7TY rmrnativ Address CHTCAGn TT. TSNOTS
Type of Ppliey: OComprehensive ?Other
LIMITS:
Bodily Injury $_7 . OQ 000. Each Occurrence Property Damage $ 250,000. Each Occurrence
$1,0110.0 Il0 - A99regate $ 500 000. Aggregate' "
Personal Injury $ t, nnn, 00(1 Aggregate
COVERAGE PROVIDED (Check Applicable Square):
OOerations of Contracmr .
Operations of SubContractor (contingent)
Does Personal Injury include claims
rela[ed to employmrnt?
Completed Onerations/Products
Contractual Liebility (broad form)
Exceptions:
AUTOMOBILE IIABILITV
-OR- _
Com bined Single limit $ Each Occurrence _
Yes No - Yes No
ID ? Governmental Immunity is waived FL] ?
3 ? Properry Damage liability includes: ..
Oamage due to blasting ID ?
13 ? Damage due to collapse FLI ?
0 ? Damage to underground facilities cl ?
[a ? _ -. Broad Porm Property damage 1-1 ?
PolicY No. RItA 8301026L__ E(fective 7-1-80 _ Expiration 7-1-81
insurance Company CONT NFN A AS(jALTY--C0MPANY Address CHICAGO, ILLINOIS
Typa of Poliey: (OCamprehensive ?Other -
LIMITS:
Bodily Injury: $ Each Person - - OR - -- $ Eath Occurrence Combined Single limi[ $ 9(1(1, f10(1. Each Ocwrrence Property Damage S Each Occurrence Coverage is provided for operation of all owned, hired and non-owned vehicles Yes No
E) 0
UMBitELLA EXCESS IIABILITY INCLUDING AUTOMOBILE LIABILITY: Policy No. Etfective Expiration
Insurance Company Address
LIMITS:
Sinqle Liml[ Budily Injury
-`
and Propr.rty Damage $ _ Each Occurrence
COVERAGE PROVIDED: Applies in excess of the coverages listed above for EmploYer's Liability, Pu61ic Liability Yes No
and Automobile Liabiliry 0 0
Are any deductibles applitable to bodily injury or property ciemage on any of the above coverages? If so, list. ? El
AGENT CARRIES ERRORS AND OMISSIONS INSURANCE " El ?
Should any of the above described policies be cancelled before the expiration date thereof, the issuing compa will endeavor to mail
fifteen days written notir.e to the beiow named certificate holder, but failure to maii such notice shall im no obligation or liability of
any kind upon the company.
Dated at *+p1s - ht' on 6-27-80 gy" ?
Auihorized Insurance Representative
' J:... . ...
CoMbuctinn Intlustry Coaperative Committee ol Minnesola - form GI.QC.401. Feb. 1961, Re.. June 1969, Rav. Jan. 7971, Fe.. Nov. 1977
L /I Ii °4i F°t?` ' ? /
11.
' CERTIFICATE OF INSURANCE - WORKh9Ef'"S COMPENSATION & LIABILI TY ONLY
This certificate is issucd as a mancr nl information only and cunfers nti riyhis upon the certificate holder. This certificate does not amend,
extend or aiter the coveraye alforded by ihe policies listeci below. ,
??7?
Project Landscaping at Elliott Auto Supply Locaunn -'???a1e__Blud Eagan, Mn.
Owner CITY OF EAGAN, 3795 Pilot Knob Road, Eagan, Mn.
Contrector Architect/Engineer _ Agent COBB. STRLCKER,_DUNPHY A;VD ZIAfMB[L'`1AA1N
WORKMEN'S COMPENSATION
00
Suuth,1,1n1s.,Mn.
Policy No 6?5- Etfective 7-1-80 Expiration 7'1-81
Insurance Company COATINliNTAL CASGALTY CO?7YANY Address CI[ICAGO, ILLINOIS
Coveroge - Workmen's Compensation, S[aturory. Employer's Liability Limit 5 100, 000. each accident
PUBLIC LIABILITY: PolicyNO. C.('P 7437568 Effective 7-1-80 Expiration_.]-1-81
InSUrar.c: Comaany--CIQgIIjQG\TM. !'AS(;ALT\' !'(1NiPACY Address CHTCAGO TT i T".OTS
Type of Poliey: OComprehensive ?Other
UMITS:
Bodily Injury $ 1,M0 000. Each Occurrence
$ 1 onn oon. n99rc9dtc
Personallnjury $1,(M,nnn Aggregate
COVERAGE PFOVIDED (Check Applicable Syuare):
Opera[ions of Contractor
Operations of SubConiractor (contingent)
Does Personal Injury include claims
related to employment?
Completed Onerations!Products
Contractual Lia6ility (broad form)
Exceptions:
AUTOMOBILE LIABILITY
Property Damage $ 250, 000. Each Occurrence
$ 500.000. Aggiegate
- OR -
Com bined Single Limit $ Each Occurrence
Yes Na - Yes No
?x ? Governmental Immunity is waived El ?
ID ? Property Damage liability includes:
Damage due ro blasting El ?
? ? Damage due to collapse El ?
11 ? Damage ro underground facilities 0 ?
ID ? Broad Form Property damage - 0 ?
PolicV No. R IA 01024 Effective 7-1-80 _ Expiration 7-1-81
Insurance Company _GONTIVENTAI,CA$jLA[,TY-OMPANY Address CHICAGO, ILLINOIS
Type of Policy: CDComprehensive ?Other _
LIMITS:
Bodity Injury! $ . Each Person - OR - $Ear.hOcwrrence CombinedSingleLimitS 500,000_ EachOccurrence
Property Dama9e S Each Occurrence -
Yes No
Coverage is provided for operation of all owned, hired and nonowned vehicles ID 0
UM6RELLA EXCESS LIABILITY INCLUOING AUTOMOBILE LIABILITY
Policy No. Etfective ExpiraUOn
InSUrance Company Address
LIMITS: . '
Sinqle Limit Bodily InIurY and ProUPrty Damage S _ fach Occmience
COVERAGE PROVIDED: Applies in excess of the coverages listed above for EmploYer's Liability, Puhlic Liability Yes No
and Automobile Liability . . ? ?
Are any deductibles appiica6le to bodily injury or properry dsmage onany of the above coverages? If so, list. . ? El
AGENT CARRIES ERRORS.AND OMISSIONS INSURANCE ' El ?
Should any of the above described policies be cancelled before Ihe expiration date thereof, the itsuing compa will endeavor to mail
fifteen days written notice m the below named certificate holder, but failure m mail such notice shall im no obligation or liability ot
any kind upon the company. -
Datedat M{iq , Minn on 6-27-80 . gy Authorized Insurance flepresentative
Consiruction Induslry CooperaU" Commlttee of Minnesola - Form C.I.C.C.701. Feb. 1961. Rev June 1969, Rev. Jxm. 1971, Rev. NoJ. 1977
CERTIFICATE OF INSURANCE - WORKMEN'S COMPENSATION & LIABILITY ONLY
This certilicate is issued as a mattcr nl information onlv and confers no rights upon the certificate holder. This cortificata doesnotamend,
extend or alter Ihe coverage afiorded by the policies listed below.
Project Landscaping at Elliott Auto Suppl Location 2855 Eagandale B1vd.,Eagan,MN
Owner CITY OF EAGAN, 3830 Pilot Knob Road, Eagan, MN 55122
Contractor
Architect/Engineer
Apent_rnuu CTRF!'KFR y)uNpH,v amn 7TMMFRMANA AddressP.O.Box_2750.i.non Sta Mols *iN 554?
WORKMEN'S COMPENSATION:
Policy No.sr 2317629 Effective 19-1-89 Expiraiion 12-1-86
InsUraoCe Comp2nyTRANSPORTATTf1N TNSIiRANC'F ('O Address CHICAGD.ILLINOS
Coverege - Workmen's Compenzation, Statutory. Employer's Liabiliry Limit $ 100 000 - earh accident
PUBLIC LIABILITY:
Policy No. ('f P 9166714 Effective 12-1-85 ExDirotion 12-1-86
Insurence Company AMFRTCdN (`ASj1Ai TV rnrrnaNV AddressCHICAGO. T.. NOT
Type of Po!icy: E]Ccmprehensive ?Other .
LIMITS:
8odilylnjury $ 502,OC1R EachOccurrence
S_10,000_ Aggregate
Personallnjury g snn,nnn Aggregate Properiy Oamage $ 750 000 _ Each Occurrence
g snn Of)0- Aggregate
-OR -
Combined Single Limit $ Each Occurrence
COVERAGE PROVIDED (Check Applicable Spuare):
Yes
Operations of Contraccor 13
Operations of Sub-Contractor (contingent) 13
Does Personal injury include claims
related to employment? (3
Completed Operations/Productf 13
Contractual Lia6ility (broad form) 13
No
? Yes No
Governmental immunity is waived ' El ?
? Property Damage liability includes:
Damage due to blasting Q ?
? Damaga due to cotlapse . Q ?
? Oamage to undergraund facilities Q ?
? Broad Form Property damage • Q ?
Exceptions:
AUTOM081LE LIABILITY
Policy No. Rne 7i rr,7377 Effective 1 7-1-RS Expiration 12-1-86
insurance Company nMFgICAN CASUALTV rnM-Poh^' Address CHTCAGO. 7LLINOIS
fYpeafPolicy: Comprehensive ?Other
LIMITS: Bodily Injury: $ Each Person - OR -
$Each Occurrence . Combined Singte Limit $ 500, 000 Each Occurrence
PropertY Damage $Each Occurrence Coverege is provided for operation ot all owned, hired and nan•owned vehicles Yes No
? ?
UMBRELLA EXCESS LIABILITY INCLUDING AUTOMOBILE LIABILITY: PolicyNo. irnrn 7166736 Effective 72-1-8 Expiration 12-1-86
Insnrance Company CnNTTNFNTAT ('ASTTA7 TY ('OMPANY Address CHICAGO. ZLLINOIS
LIMITS:
. Single Limit Bodily Injury
and Properiy Damage $ 5 f1f1n n0n Each Occurrence
COVERAGE PROV IDED: Applies in excess of the rnverages listed above for Employet's Liability, Public Liability Yes No
and Automobile Liability El 11
Are any deductibles applicable to bodily injury ar property dema9e on any o} the above coverages7 If so, list. ? El
AGENT CARRIES ERRORS AND OMISSIONS INSURANCE ' m 1:1
Should any ot the above descri6ed policies he cancelled before the expiration data thereof, the issuing company vri11 IrAlgRpNARXnail
fifteea days written notice ro the Emtmecnamed certificate holder,
R7dOC?AdxtAftOC1?C]?OR}{ORR . ?n ?? l? s? .. ? ? ? :?tiiV
Dated at- MPls MN on 7-1-86 By ????--?-??j? '
Authorized Insurance Representative
Comtruction Induitry Coope.auve Commite" ol Minneiow - Porm C.I.C.C.J01, feb. 1981, Rav. June 1969, Rw. Jsn. 1871, Rw. Nov. 1977