1i. Fees for hazardous materials incident 1 ,
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_,.. , 690•COULTER•DRIVE • P.O:IBOX 147 • CIrIANI6ASSEN,. MINNESOTA 55317
- ' (612).937 -1900 • FAX•(612)937 -5739
111.
111 MEMORANDUM 'net I
tibJecte
TO: Don Ashworth, City Manager / `� }�- --- -�
II Submtt#ap hr 6or
FROM: Scott Harr, Public Safety Director ,y
1! DATE: May 28., 1992
SUIT: Water Obstacle Permit
1 This memo is regarding a water obstacle permit submitted bb the
g g P Y
.Minnewashta.Ski: Club for a slalom ski course. Per our discussion,
I i I understand that this request was originally brought to the City
a number .of years ago, being granted each• year by the City of
Chanhassen and the Carver County Sheriff's Department - Water Patrol
II Division. The applicant has provided verification of insurance by i
the club for use of the course, as well as. agreeing that no skiing
would occur .before 7 a.m., or on holidays or weekends. Councilman
Richard Wing had been involved with the granting of this permit
i back when he was on the •Public Safety' Commission, and has verified
this information as well.
Ii If ,there are no concerns, I will issue this permit so that the
applicant may proceed with this summertime activity as soon as
possible.
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1
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Ill
t4 PRINTED ON RECYCLED PAPER
II CITY OF CHANHASSEN
il 690 Coulter Drive
Chanhassen, Minnesota 55317
937 -1900
WATER OBSTACLE PERMIT
(Section 6, Ordinance No. 73) / ____^ Th
Date: S�/ /r2 Application Fe $2520
II (Non- refundable
Paid ,Sec_ ,-4_14-,(1.,()
APPLICANT -E ‘� C /7 y. 2 7-.9z--
1 $ / - J NAME : 6 lit vl .J !/1/4
11 ADDRESS: / / ,1
_
TELEPHONE NO: Home: 77 3 3 Work: 94l 0) ' :
II ORGANIZATION
I NAME: ,4- - C U G:, s#4.( $ f c , 4_
ADDRESS:
I TELEPHONE NO: ,
Describe nature of Organization: 6 - ,.. (z. - (l6 - /--7,)-
II
TYPE OF WATER OBSTACLE
II Ski Jump
II Slalom Ski Course
Diving Tower
II %
Other (please specify)
SIZE (Dimensions, Height, etc.): j >. k - 7c e ,-
II LOCATION (Include Map) : A S7 (- L c 1A- i4 H rt./ ct a r<
Method used to Reflectorize Obstacle: ( z�� 4 c z,.74,
I Dates Permit Requested: /7/.?
l 1 /5 2- — —/ ` P Z
1
II If this is a Special Event, please describe: /c/ C)
II
II
PERSONAL L IABILII T S TATE FARM FIRE AND CASUALTY COMPANY
I UMBRELLA - _
c- APPLICATION " - ^IU}OLUie;rtQU "W Ot l 8lem ngton;:lllinQis. pL3q tIDJU ".1. >Qfi62f
v "ri01 .end. ;of. ;i A-• .._ ,a,,4vuuooww: i c4" -F . ', '+�Ite.!.a'„} .4' • 0.ov" -u� 1 ..
- : Policy, N O . : : a " " inn:. 4 ::1 . tarsii - t ='•' t 1 E it1_ ` y .i I , e )." :' w P.m! X� Term: 12 Mont
NAME Lest a°'""C ' � // / ' 'E rar�m j l,,e t d S Name «.- Spouse•d Fist flame and Mldae millet (lf appiable) •
Please print
6• c r� e � , X/ ' S
N urlber 1 ..�`c �",;� s. a4' . sS }� t < 'rF'r l. �a -•.; 7f7 i: c! - - -F f 1< ¢ ° 7 r. )!{, .,
ddress- . T , 7" f -I , i11., , y s f •� f fs a / s ; :l f ° ' 1 - . ' :,k. ' � - v it`s.- ,4
I
_.-. -
. rz t.c•t Yt� l��a.. o� s�.� s� ?�_i ,Y� " � , �J �2i'fC.��$'f� t - '
,'slice -,L 3�,f,} e � A Cg ' r r ,, r °t,Iff(rtf� ` t tb; T r'., s D H
t „ ?y: • Cr, ttiK.:� Y - :.^ ' x-{.95 's..'7., +1 . i e ! ms ) !`11419P0.!".-1,.:, -
' 9
� E E•..1 i' 1f ' `r (`L
V - - - .• - -. q•: i ': 17Fg. - t. , Yae •v��.E V:: :f - Y:�.a,.. ^
D Does the applicant own pro - :• is perty or at any time reside outside the' Unit or "Canada? _ x « -,_ . •- ;, s " ` :._. _ : : If yes, DO NOT BIND and explain in'Remarks,
= st,tf."41 satxa -ems .aft - v.ttoanal ilere'14F9 �Jlss!vA , • - %-" <"; ", - , _ - - .
a Specific occupation or profession and employer of EACH househol member 21 years or older (use Remarks if necessary)
� / 1 1 t
Indicate if coverage is desired or an underlying policy provides coverage for any of Family Corporation or Family Office or Business in Professio
the following eligible exposures and complete appropriate section on other side: ❑ Partnership (including farms) ❑ Farm ❑ Rental Liability ❑ the Home ❑ Liability
During the past 3 years, has the applicant or any household member had any major traffic violations or convictions Yes
If yes, DO NOT BIND and explain in Remarks
(as defined in the Auto Rate Manual) or at -fault liability claims?
Has any insurer or agency canceled or refused to issue or renew Umbrella Liability or any applicable Yee ° X If yes, DO NOT BIND. Give previous insuran
underlying insurance for the named applicant or any household member within the past 3 years? company, policy number and details in Remar
With respect to any insured or exposure on any of the existing underlying liability policies, are there any : Yes 7
I/ es, explain in Remarks
reduced limits of liability, reduced coverage or restrictions? y
Give the number of exposures for each of the following:
Owner O wned or leased autos (including n. : Unl icensed off - road
p ( g , :Company cars or furnished autos T . Farm
. residences - licensed recreational vehicles) t..,.. .. - :- recreational vehicles I J T : (provide coverage details in Remarks) vehicles
+
2 Total# of drivers # of under- te r-• Does the applicant own : Yes it yes, complete the following if State Farm Other company (give complete
1. in household =• - age drivers l � or hire any watercraft? : : over 25 hp or sailboat over 26 ft. ❑ Boatowners ❑ details in Remarks)
CC Is there a surcharge under an accident record rating or similar program? Yes : / If yes, policy must be rated as Class 3 or 4 1
cc
o COMPLETE THE FOLLOWING OPERATOR INFORMATION IF ALL UNDERLYING AUTO POLICIES ARE NOT WITH STATE FARM OR IF THE STATE FARM AUTO POLICIES
j HAVE NOT YET BEEN ISSUED. PROVIDE CERTIFICATES OF INSURANCEFORALL UNDERLYING.MOTOR VEHICLE POLICIES THAT ARE OTHER THAN STATE FARM.
NAME(S) OF ALL MOTOR VEHICLE OPERATORS (USE REMARKS IF NECESSARY) DATE OF BIRTH : OPERATOR'S LICENSE NUMBER & STATE OF ISSUA
!-1•1-, :;�� ' / ~ :. I'l ' /c -/ 5G T 5/ - f / c I -if,:
1
LIMIT OF / COMPANY PERSONAL LIABILITY SI MILLION PREMIU
LIABILITY $ / .000.000 (IgINDefSee ^U Slide Fadn, We writ ^I �°;a NOT POLICY NUMBER MINIMUM POLICY LIMITS UMBRELLA COVERAGES (FOR CALCULATIO
f XHomeowners Basic premium $100,000
E Liability � ' ($300,000 r ru l 'nimum l o ( a ^a z ns
o° d / I"
❑ Personal Liabilit State Farm
IL . - .-i /7� Class: $ J
cc ❑ Farm Liability . re ntal dwellings)
O. Credit for less than
i • Automobile " ' IJ - 7, y BI PD 2 autos or 2 drivers • - ".-'
a .- ..._....... I — l','' z q Per Per Autos not included
F Uninsured /Underinsured State Farm t ` Person Accident $25,000 in basic premium
-4' r 7
Motor Vehicle ✓ r '7 ,5 I e 4, ) $100,000 $300,000 Uninsured /Underins. ; ]! f 6 '0
• II the applicant does not want Uninsure Motor Vehicle Coverage, or does not have OR Motor Vehicle (autos) 7`
O Uninsured'Underinsured Motor Vehicle Coverage limits of S100.000$300 000, the Rejection below $300,000 Single Limit Uninsuredt ns-
p m u st be signed. eh. (rec. veh.)
D.
O Watercraft I $100,000 Single Limit Farm vehicles ----
z I —
T. I Per Claim Agg•ega,e Additional p • C
Additional Exposure $ $ /
w I exposures ;
p Per Claim Aggrega,e Professional r ----
Z
Professional Liability liability I
Effective Expiration
date date $ ' $ Farm exposure
—
REJECTION OF UNINSURED/UNDERINSURED MOTOR VEHICLE COVERAGE Territory Subtotal �C1 /,, v,. i
In keeping with the laws of my state. I have been offered the opportunity to purchase Uninsured/ ($1 million premium) �C� i/
Underinsured Motor Vehicle Coverage, and I reject the opportunity to purchase this option as MPP $1 million premium
part of this application. Acct. No. !'"' X excess factor
❑ 1 reject Uninsured /Underinsured Motor - Vehicle Coverage on all vehicles. Amount
1=1 1 reject Uninsured /Underinsured Motor Vehicle Coverage on recreational vehicles only P $ /0/ Additional
lSJ premium charge
I understand that this acknowledgement of rejection will be applicable to the policy applied for, all Balance
future renewals of the policy, and on all replacement policies until 1 make a written request to Due $ - 0 TOTAL PREMIUM $ �6( f�6
cn add this coverage.
cc Applicant's UNDERWRITING USE ONLY
< Signature X -- - -- Approved By Date GFU Code Date
z I understand that provided by ❑ not provided until this application is approved I •
- coverage is: this application. - by the State Farm Fire and Casualty Company
- Underwriting Department. ' - = `- Agent's Code Stam °°°��� Date and Time
- 1 am applying for the - insurance indicated, and the information on this application is correct. -The - -- - 133 LEMON OF HONOR — "1 '1 of Application ,
minimum required policy limits are in force, and all land vehicles are insured. I understand that - i Mo. Day Yr
the premium shown above must comply with State Farm's rates and may be revised. I also
GREGORY LOFFHAGEN 3626
a . understand that State Farm may obtain traffic violations reports at any time for any person
named as-a driver of he .ured motor j ve - +. 1
v
ApplicanYs , D . Hanson [;�,_,,
n _ J z �!}
Signature X : ) f ✓ � p .. '`''YF - - �- - � .- - ....,.. - , ... _. .. - - / .m.
-
F7 - 2606 a.4 Rev 8 - 90 INDICATE REMARKS ON OTHER SIL'