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CITY OF GEM LAKE <br />1369 East County Road E Gem Lake, MN 55110-5231 Phone: 651.426.6443 Fax: 651.426.6444 <br />LAND EXCAVATION & RECLAMATION PERMIT APPLICATION <br />Contractor/Applicant <br />Contact / Title <br />Street Address <br />City, ST zip <br />Telephone / Fax <br />MN License # <br />Property Owner <br />Contact / Title If Company <br />Street Address <br />City, ST Zip <br />Telephone / Fax <br />Construction Street Address <br />Legal Description or PIN # <br />Current Zoning & Use <br />Occupancy (To Be Used :\s) <br />TYPE OF CONSTRUCTION, VALUATION & CALCULATIONS <br />( } <br />Residential <br />( } <br />New Construction <br />( } <br />Wetlands Are Included In Work Areas <br />{ ] <br />Commercial / Industrial <br />{ } <br />Remodeling / Addition <br />( } <br />Work Includes Tree Removal <br />VALUE CALCULATIONS <br />GRADING CALCULATIONS <br />FILLING CALCULATIONS <br />Total Job Valuation (Contract Attached) <br />$ <br />$ <br />Total Property Size (Site Plan Attached) <br />acres site total <br />acres site total <br />Total Land To Be Disturbed/Reclaimed <br />acres disturbed/reclaimed <br />acres disturbed/reclaimed <br />Total Volume of Fill Removal / Deposit <br />yards to be removed <br />yards to be deposited <br />Work Description (road, sewer, etc - Plans Attached) <br />Reclaim Fill Source #1 (City & Site - Assay Attached) <br />Reclaim Fill Source #2 (City & Site - Assay Attached) <br />Reclaim Fill Source #3 (City & Site - Assay Attached) <br />EXCAVATION PERMIT FEES <br />LAND RECLAMATION PERMIT FEES <br />Minimum Project Fee or <br />Disturbed Acres x $/acre Disturbed <br />$ <br />Minimum Project Fee or <br />Cubic Yards > 400 x $/Cubic Yard <br />$ <br />Minimum Engineers Inspection Fee or <br />Disturbed Acres x $/acre Disturbed <br />$ <br />Minimum Engineers Inspection Fee or <br />Disturbed Acres x Vacre Disturbed <br />$ <br />State Sur Charge <br />$ <br />State Sur Charge <br />$ <br />City Administrative Charge <br />$ <br />City Administrative Charge <br />$ <br />Other <br />$ <br />Other <br />$ <br />TOTAL <br />$ <br />TOTAL <br />$ <br />Applicant Signature <br />Date: <br />City Clerk Signature <br />Date: <br />Chief Building Official Signature <br />Date: <br />0 Approved n Denied Total Fee Paid: $ <br />Check # <br />NOTE: If this application is denied or the permit revoked, reason for denial or revocation must be submitted to Applicant in writing. a -file: Pemnts\Apply\stiramng.wpa <br />