Lake Saint Louis Building Department Blasting Permit Application $75.00 Fee Mail To: City of Lake Saint Louis (Building Dept) LEAVE BLANK: 200 Civic Center Drive PERMIT NUMBER ISSUED Lake Saint Louis, MO 63367 DATE RECEIVED: / / 636-625-1200 RECEIVED BY: FEE COLLECTED: YES NO RECEIPT # CHECK # NO. OF ATTACHMENTS: PERMIT PERIOD: FROM / / TO / / POLICE DEPT NOTIFIED: Chief of Police LSL FIRE DEPT. APPROVAL Fire Department Representative SECTION I: GENERAL 1. Name of Applicant: 2. Applicant s Address: 3. If Corporation, the State of Incorporation: 4. Has the applicant, any subsidiary, affiliate, or persons controlled by or under common control with the applicant, ever held a blasting permit in any state or political subdivision which in the five year period to the date of the submission of the application has been suspended or revoked: YES NO 5. Name of person to conduct blasting: 6. License number of person to conduct blasting: SECTION II: PROPERTY DESCRIPTION (PURPOSE OF BLAST) 1. Description of the purposes for which the blasting permit is to be used:
SECTION III: LOCATION OF THE BLAST 1. Location of Blast/Legal description for the requested permit area: 2. Is the applicant also the owner of the above described land? YES NO For any land that is not owned by the applicant, attach documents which applicant bases its legal right to enter and commence blasting. SECTION IV: SIZE OF BLASTS 1. Seismic reading of Blasts: SECTION V: REQUESTED DURATION OF BLASTING: From: / / To: / / SECTION VI: MAPS TO INCLUDE NEAREST STRUCTURES 1. Attach maps of a scale of not less than one inch to two hundred feet clearly showing the following: A. The land proposed to be affected during the period of the permit including all boundaries of the land to be affected. B. Location of the closest structures to the permit area in any direction (200 feet minimum unless authorized by the Chief Licensing Official). C. All easements of record, public and private, which cross the permit area.
SECTION VII: IDEMNITY COVERAGE 1. Name of Bonding or Insurance Company: Address: 2. List Amounts and Types of Coverage: A. B. C. 3. Attach Certificate of Insurance of Bond Documentation. SECTION VIII: RECLAMATION 1. Maps indicating existing conditions of the land: A. An existing topography map of the land, with a contour interval of not less than two feet. B. Features such as soil conditions, drainage ways, adjacent roads or highways. 2. A statement of the proposed use of the proposed use of land following reclamation. 3. A plan of reclamation including the following: A. Map indicating the conceptual grading plan for reclamation. B. Map showing a proposed use plan showing roads, railroads, easements, open space and other uses. C. Estimated schedule of the phasing for the accomplishment of the proposed reclamation plan:
SECTION IX STATEMENT OF QUALIFICATIONS: 1. A statement describing the applicant s educational training regarding blasting: 2. List of clients of the applicants including address and telephone numbers: Name Address Phone Number 3. List names, addresses, and telephone numbers, of the consultant hired to monitor blasting: Name Address Phone Number SECTION X: ATTACHMENTS 1. List the Attachment Submitted: A. F. B. G. C. H. D. I.
E. J. signature of applicant s representative Position and Title CITY OF LAKE SAINT LOUIS BLASTING PERMIT PERMIT # This permit authorizes to conduct Name of Applicant/Organization blasting in the area described within their submitted blast permit application. The recipient of this permit must comply with all Federal State and Local laws to include parameters/guidelines detailed in Lake Saint Louis Municipal Ordinances Sections 515.010 through Section 515.130 and all other stipulations/requirements detailed in the recipient s blast permit application including but not limited to those that relate to blasting and noise abatement. The recipient of this permit shall have a licensed blaster on site at all times during blasting. The designated licensed blaster will be with a license number of. The emergency contact representative for the recipient of this permit is with a phone contact of. The recipient of this permit shall notify the Lake Saint Louis Police Department of their intention to blast prior to commencement of blasting each day (636-625-8018). The recipient of this permit shall additionally notify the Lake Saint Louis Building Department of their intention to blast prior to the commencement of each blasting session (636-625-1200). Blasting is restricted to the hours of 8:00 a.m. until 4:00 p.m. Monday through Friday. Blasting may begin on / / at and will end on date time / / at which is when this permit expires unless date time
modifications of this permit is requested by the recipient and approved by the City of Lake Saint Louis. This permit is hereby authorized by the City of Lake Saint Louis Chief Licensing Official identified as: Michael Pavlakes signature of Chief Licensing Official / / date cc Chief of Police cc Police Dispatch cc Lake Saint Louis Fire Protection District