HomeMy WebLinkAbout06/08/1982 TENTATIVE AGENDA
ADJ .REG.SESSION SHAKOPEE , MINNESOTA JUNE 8 , 1982
Mayor Reinke presiding
1] Roll Call at 7 :00 P.M.
2] Convene as the Board of Equalization:
a] Summary Presentation of 1982 Assessed Valuations by
Robert Schmidt of Scott County Assessor' s office
b] Questions by Board of Equalization Members
c] Review and Appeal of Petitioner' s Assessed Value/Market
Value and Equalization (petitions received thus far maybe
resolved by Tuesday)
1 ) Wallace Perry (L21 & 22 of G & 0 Addition) 27-002-054-0
2) Eugene Hauer (old farm bldgs. on 4.3 acre site
in Sec . 8-115-22) 27-908-068-0
3) First National Bank of Shakopee (L1 , 2,3 & W1/24, Blk 23)
4) Pouliot Designs, L1 , B1 , Valley Park 2nd - 27-067-001-0
5) Pouliot Designs, Outlot A, Valley Park 2nd' - 27-067-002-0
6) Pouliot Designs, Lot 1 , Blk 1 , Bailey Park 4t.6 -
27-077-001-0
7) Other residents in audience
3] Adjourn Board of Equalization to . . .
4] Seal & Chip (Seal Coat) Program and Pavement Analysis (bring item
10i of June 1st)
5 ] Firemen ' s Fitness Program (bring item 10m of June 1st agenda)
6] Other Business :
a]
b]
c]
7 ] Adjourn to Tuesday, June 15th at 7 :00 P .M.
John K. Anderson
City Administrator
<^�. CITY OF SHA OPEE
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i-" ; 129 East First Avenue, Shakopee, Minnesota 55379 -
1. MEMO
TO: Shakopee Board of Review
FROM: Leroy Arnoldi, Deputy County Assessor
SUBJECT: K-dart Warehouse
DATE: June 8, 1982
It has been called to my attention, by city staff, of their wish for a re-
view of the appraisal done by Peter J. Patchin & Associates, Inc., on the
subject property, June 30, 1981.
I have done so and the only item that I would have any qualm with would be
the estimated functional incurable depreciation as described and indicated
on pages 51-52.
However, with the dollar amount representing less than one half of one per
cent of the total value, it would not be worth disputing, as this technique
does not necessarily violate standard appraisal practices.
The total valuation of $16,136,500 would also be deemed proper when consider-
ing the existing level of assessment, which is used as comparison basis in
mass appraisal to ensure equality.
I would therefore recommend the K-Mart Warehouse valuation remain at $16,136,500.
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`oic„... CITY ® F S AKOPEE
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t�• �!.) 129 East First Avenue, Shakopee, Minnesota 55379
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MEMO
TO: Shakopee Board of Review
FROM: Robert N. Schmitt, Scott County Assessor's Office
SUBJECT: Eugene Hauer Property •
DATE: June 8, 1982
#27 908 068 0
Mr. Hauer has expressed concern over the increase on the above noted
tax parcel in taxable valuation for the 1982 assessment. The value
was increased from $30260 to $64800 due to a new building which was
partially completed for the 1982 assessment and added $1200 to the
market value, and due in large part to the assessment of buildings
and grain bins and a silo that had not previously been assessed.
The buildings added to the assessment records for the 1982 assessment
are: garage 22 x 31 valued at $682
quonset valued at $2000
1981 shed valued at $1215
2 10M Bu. Bins valued at $8000
2 10M Bu. Bins valued at $10200
Stave Silo valued at $1000
The above additions plus changes in buildings already valued as well
as one subtraction of a storage tank, equals a total increase in valu-
ation of $36847.
I believe these values are accurate and fair when compared to similar
buildings on farms thoughout Scott County.
F
„,,ICITY OF SHAKOPEE
o :11- ” ; t 129 East First Avenue, Shakopee, Minnesota 55379
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MEMO
TO: Shakopee Board of Review
FROM: Robert N. Schmitt, County Assessor's Office
SUBJECT: Eugene Pearson Building •
DATE: June 8, 1982
#27 001 182 0
•
Mr. Pearson is contesting the value placed on his building located
on lot 6 block 24 of the City of Shakopee. This building was part—
ially completed for the 1981 assessment at a rate of 70% according
to the field card for the parcel. For the 1982 assessment the build—
was considered to be 100% completed and the appraisal of it was based
on this. The value for the 1981 assessment at 70% on the buildings
was $21300 lancj and $76600 buildings for a total of $97900.
The 1982 assessment has the value at $21300 land and $109100 build—
, ings for a total of $130,400. .
The rates for this building were taken from Marshall—Swift Valuation
Manual and would be used fsimilar uild" i _ in the county. A
��any)/i Mg/7,70 "X < . 9/1
The rates used are based on a 3136 square f•�t�dia uildin part over
basement and part over crawl space. A 672 square foot garage, part
heated and part unheated. A central air conditioning unit which
serves the entire building.
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oaf CITY OF SHAKOPEE
. ,�$ - 129 East First Avenue, Shakopee, Minnesota 55379
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,~�''A.--- MEMO
TO: Shakopee Board of Review
FROM• Robert N. Schmitt , Scott County Assessor's Office
SUBJECT: Pouliot Designs Corp. • ,
DATE: June 8, 1982
#27 067 001 0
#27 067 002 0
#27 077 001 0
We received a letter from Mr. Kenneth W. Voss, the tax representative
for Pouliot Designs, stating his wish to have the above property noted
in the minutes of the 1982 Shakopee Board of Review. This is to ensure
that all avenues for appeal remain open to the corporation.
The values on the above properties have not been increased for the 1982
assessment and are as follows:
#27 067 001 0
Land $89600 '
Buildings $951065 Lot 1 Block 1
Total $1,040,665 1 Valley Park 2nd
#27 067 0020
Land $450
Buildings 0 Outlot A
Total $450 Valley Park 2nd
#27 077 001 0
Land $83000
Buildings 0 Lot 1 Block-1
Total $83000 Valley Park 4th
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CITY OF SHAKOPEE
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,(.,,r . 129 East First Avenue, Shakopee, Minnesota 55379
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MEMO
TO: Shakopee Board of Review
FROM: Robert Schmitt, County Assessor's Office
SUBJECT: 1st National Bank of Shakopee
DATE: June 8, 1982
#27 001 158 0
At a meeting in the County Assessor's Office this morning with Mr. Connie
Schmid of the 1st National Bank, the Bank's 1981 and 1982 valuations were
discussed. Mr. Schmid had expressed concern with the increase in taxes
payable in 1982. This was a result of both the increase in mill rates
and a increase in valuation for payable 1982 of approximately $200,000.
This increase was done to equalize 1st National Bank with other banks in
the county.
The increase which was placed on the bank for the 1982 assessment was for
the new addition to the bank which was built during -1981. The increase
was for $212,600.
Mr. Schmid expressed his understanding of what was done and also for the
rates used. This problem would appear to be solved a the present time
with no:need for consideration by the Shakopee Board of Review.
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DON D. MARTIN
SCOTT COUNTY ASSESSOR
COURT HOUSE 112
SHAKOPEE, MN. 55379 (612)-445-7750, Ext. 115
Deputy:
LEROY ARNOLDI
SUMMATION OF THE 1982 ASSESSMENT FOR SHAKOPEE
The 1982 assessment of the City of Shakopee was done by the Scott
County Assessor's Office and involved the following work:
Approximately 250 new building permits were issued in Shakopee
during 1981. These new structures were inspected by the County Assessor's
Office for the 1982 assessment and values placed on them. Partial comple-
tions from the 1981 assessment were rechecked during the 1982 assessment to
record the completion progress for this assessment year. This involved
roughly 100 parcels. The 25% reassessment for Shakopee was also carried
out and involved approximately 1000 parcels . These parcels were located
in the plats of Original Shakopee, East Shakopee, Nehl's Addition, Ameri-
can Legion Addition, Macey's Addition, West View 3rd, 4th and 5th Additions,
Registered Land Surveys #24 and #66, Killarney Hills, Valley Park lst,
Marceline's 1st Addition, Strobel's 1st, Weinandt Acres, Valley Rich 1st,
and new plats recorded during 1981. The 25% reassessment involved parcels
which were last checked in 1974 to 1978. The work involved periodically
checking the interior of certain homes for finished basements or extra
baths. The exteriors were also viewed for condition as well as for decks
or other extras. The Shakopee assessment also involved the normal number
of properties whose owners questioned the previous assessments. These
properties were rechecked and involved 20 to 30 parcels. The land rates
used in this assessment remained the same as had been used in the 1981
assessment. The square footage rates used for the structures which were
checked were those used on all properties in Scott County in the past
other than Shakopee, and the taxable amounts differed very little from
that used in Shakopee in the 7.77 7% - 2% higher for the County's rates) .
The field work for Shakopee was started on October 21, 1981 and completed
on January 22, 1982. The calculation of values was started in November,
1981 and completed in May, 1982. The values were calculated by myself
and Leroy Arnoldi, Chief Deputy County Assessor.
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04/4`Pt) 46- tit-i
Robert N. Schmitt
Scott County Assessor's Office
An Equal Opportunity Employer
,`,,,o ,, CITY OF SHAKOPEE
4:Pi • V LV, 129 East First Avenue, Shakopee, Minnesota 55379 :�
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MEMO
TO: Shakopee Board of Review
FROM: Robert N. Schmitt, Scott County Assessor's Office
SUBJECT: 4-Plex owned by Wallace Perry '
DATE: June 8, 1982
PARCEL NO. 27-002054-0
Mr. Perry is questioning an increase in the valuation of his 4-plex located
on Lots 21 & 22, Block 8 of G & 0 Addition. The valuation was increased
from $67280 in 1981 to $81500 for 1982. Part of the increase was due to the
addition of two 8 x 12 decks. Also, the lot values were increased to
$20000 from $14100 to put these values in line with what is used in other
parts of the county for multi-family zoned areas. This was an error on my
part because the other areas of this type in Shakopee did not receive an
increase in lot values for the 1982 assessment. I would therefore recom-
' mend a reduction in the lot value of Mr. Perry's property back to $14100
for .the 1982 assessment.
The structure values for the 1982 assessment compare well with other 4-plexes
located in Shakopee. These properties range from $36.85 per square foot
to $45.15 per square foot taxable value on the 4-plex depending upon the
size and age of the building. Mr. Perry's 4-plex is currently at $34.35
per square foot. I think this is in line with the comparables and should
not be changed.
After meeting with Mr. Perry this afternoon it was agreed upon by our office
and Mr. Perry, to reduce the land to the above noted $14100 and keep the
structures at $61500 for a total 1982 market value of $75600.
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' f DATE -r'd�
TABLE 2 V
/ C1 ,
DESCRIPTION OF GENERAL STRUCTURAL CONDITION RATINGS
STREET
Racing Description
ROM S New pavement, good condition, no cracks.
_TO --' 4 Cracking beginning to develop as longitudinal
cracks in wheelpath.
3 Large pattern of cracks developed (map cracks).
BY 2 Pattern smaller (alligator cracks).
1 Small pieces of pavement are thrown out by
traffic (erosion).
TABLE 3
TABLE 4
RATING FOR LEVELS OF PAVEMENT SURFACE WEAR RATINGS FOR LEVELS OF WEATHERING
(a) ABRASION WITH NO SEAL COAT (a) PAVEMENTS WITH NO SEAL COAT
Des tri elan
Rating Description
i Mat uniforses orityetil color across surface.
Coarse aggregatewwe in wheelpath but not protruding. 5.0 Bitusdnoua surface original color except possibly in wheel
, Coarse aggregate shows yn vheelpech and protrudes up to path.
1/16 in. or whealpath is Vocn down up to 1/16 in. 4.0 Surfaceis color of surface aggregate, especially between
vheelpaths.
Coarse aggregate protrudes in whealpath more than 1/16 in.,
3.0 0 Coarse aggregate protrudes between wheelpeths.
or mat la worn down more than 1/16 in.
More than 20 percent of coarse aggregate is kicked out in 2.5 Random small cracks beginning to form, mostly between
the wheelpath. wheelpathe.
2.0 Random cracks developed into a pattern or blocks (not
related to loading).
(b) ABRASION WITH SEAL COAT 1.0 Coarse aggregate or chunks of surface being eroded out.
arise Description
S Surface uniform original color of seal coat across the
surface.
4 Color lighter in wheelpath. (b) PAVEMENTS WITH A SEAL COAT OR SURFACE TREATMENT
3 Up to 25 percent of seal coat aggregate kicked out in
whealpath.
Rating Description
2 Seal coat aggregate eroded away, showing original surface
in the wheelpath. S Seal coat aggregate intact and in condition as constructed
1 Aggregate from original surface being kicked out in wheel- 4 Seal coat aggregate appears "drier" ber.een wheelpaths (up
path. to 10 percent eroded off).
3 10 percent up to 50 percent of seal coat aggregate eroded
off (both wheelpaths).
(c) BLEEDING WITHOUT AND WITH SEAL COAT 2 Seal coat aggregate is more than 50 percent eroded off be-
tween wheelpaths, leaving only bituminous material covering
t.LI& Description the original surface.
5 Mat uniform and original color across surface. I Seal coat is essentially all eroded off and the original
surface is beginning to erode./
4 Surface dark in wheelpath due to mix appearing richer in
wheelpath.
3 Bituminous material filling surface in vheelpath over 25 RUT DEPTH
percent of length.
. Surface richer and bleeding somewhat along more than one-halt
of the length in wheelpath. MAJOR MINOR NONE
vheelpath rich and bleeding along entire length of pavement.
TABLE 5
TABLE 7
RATINGS FOR LEVELS OF SKID RESYSTANCE DZCBIfIOIgs OF RATINGS /OR TRANSVERSE AND LONGITUDINAL CRAGS
BASED ON VISUAL EXAMINATION (a) OPENING
•
=tel Description Rating Descri.tion
S Good, coarse surface texture. 5 Hairline or filled.
.S Good, gritty surface texture.
4 1/16 to 1/8 in. open
4 Pair, coarse surface texture. 3 1/8 to 1/4 in. open
.5 Pair, gritty surface texture. 2 1/4 to 1/2 in. open
3 Aggregate slightly polished or wheelpath slightly darkened 1 More than 1/2 in. open
with excess asphalt.
2 Aggregate polished or wheelpath darker due to excess asphalt
1 Bleeding condition.
(b) CRACK ABRASION OR EROSION
S No wearing back of cracks.
4 Slight wearing of edges (mortar).
3 Some coarse aggregate eroding out.
2 Crack eroded back 1/2 vey through the surface mix.
TABLE 6 I Eroded more then 1/2 way through the surface mix.
RATINGS FOR LEVELS OF UNIFORMITY
Rating Description (c) MULTIPLICITY •
5 Good
S No associated cracks.
4 Streaked 4 A few associated random hairline cracks.
3 Crack-filling
3 Map cracks developed, along with transverse and longitudina,
2 Blotchy cracks.
1 Multiple Spot Patching 2 Alligator cracks developed, along with transverse and longi-
tudinal cracks.
1 Multiple cracks have broken away from surface.
STREET CONDITIONR E
SU V Y
Date: -9/3 /K 2
STREET 2/tic/ P ��c 5 LENGTH
TERMINI _ 11.1,10<.V 4 TO
YEAR CONSTRUCTED LAST SEAL COAT LAST OVERLAY
STRUCTURE Type Thickness in G.E. Factor G.E.
Surface, (D1) _
Base, (D2)
Subbase, (D3)
TOTALS - - G.E.=
Laboratory
Embankment R-Value
< Estimated
TRAFFIC Equivalent Loads (I-N18)
AADT Since last O.L. or construction
Speed — Future
5 yr. 10 yr. 20 yr.
CONDITIONS
Roadmeter a
PSR / Uniformity
\ Panel
Surface Condition Crack Conditions
Structural ( Opening r
{' Abrasion Abrasion
Surface Wear " 2 ------
Bleeding Mult.
Weathering `� Rut Depth, in. / Q1.J<'
Number _
Skid Resistance / i
Rat
2 ng TOTAL S2 = SuR = 7
N
SIDEWALK CONDITION :
SIGNS, UTILITIES
AND OTHER IMPROVEMENTS
•
RATE" `' j ` f
TAILS 2 L
DESCRIPTION Or GENERAL STRUCTURAL CONDITION RATINGS
STREET / ✓ ✓
Rating Deacriprion
:ROM TO New pavement, good condition, no cracks.
Cracking beginning to develop as longitudinal
cracks in wheelpath.
3 Large pattern of cracks developed (map cracks),
3Y
2 Pattern smaller (alligator cracks).
1 Small pieces of pavement are throve out by
traffic (erosion).
TABLE 3
TAUS 4
RATING FOR LEVELS OF PAVEMENT SURFACE WEAR
(a) ABRASION WITH NO SEAL COAT RATINGS FOR LEVELS OP WEATHERING
(a) PAVEMENTS WITH NO SEAL COAT
tint
Desert tion
3 Mat uniform and original color across surface. _ tib — Description
y
Coarse Aggregate showsl wheelpath but not protruding. 5'0 bituadnous surface original colgr'except possibly in wheel
3 Coarse aggregate shove in whaelpath and protrudes up to pew'
1/16 in. or whsalpath is worn dons up to 1/16 in. 4.0 Surtsey) is color of surfyit aggregate, especially between
Coarse aggregate protrudes in wheelpath mere then 1/16 in., wheelpaths. \
or mat is worn down more than 1/16 in. 3,0 Coarse aggregate protrudes between wheelpatha.
More than 20 percent of coarse aggregate is kicked out to 2.S Random small cracks beginning to form, mostly between
the wheelpath, wheelpaths,
2.0 Random cracks developed into a pattern or blocks (not
related to loading).
(b) ABRASION WITH SEAL COAT 1.0 Coarse aggregate or chunks of surface being eroded out.
haat - Description
5 Surface uniform original color of seal coat across the
surface.
4 Color lighter in wheelpath. (b) PAVEMENTS WITH A SEAL COAT OR SURFACE TREATMENT
3 Up to 25 percent of seal coat aggregate kicked out in
wheelpath.
Rating Description
2 Seal coat aggregate eroded away, showing original surface
in the wheelpath. S Seal coat aggregate intact and in condition as constructer
1 Aggregate from original surface being kicked out in wheel- 4 Seal coat aggregate appears "drier" between wheelpaths (u2
path. to 10 percent eroded off).
3 10 percent up to 50 percent of seal coat aggregate eroded
off (both wheelpaths).
(t) BLEEDING WITHOUT AND WITH SEAL COAT 2 Seal coat aggregate is more than SO percent eroded off be-
tween wheelpaths, leaving only bituminous material coverin
Sta. Description the original surface.
S Mat uniform and original color across surface. 1 Seal coat is essentially all eroded off and the original
surface is beginning to erode)
4 Surface dark in wheelpath due to mix appearing richer in
wheelpath.
•
3 Bituminous material filling surface in wheelpath over 25 RUT DEPTH
percent of length.
Surface richer and bleeding somewhat along more than one-half
of the length in wheelpath. MAJOR MINOR NONE
Wheelpath rich and bleeding along entire length of pavement.
TABLE 5
TABLE 7
RATINGS FOR LEVELS OF SKID RESISTtNCE DESCRIPTIONS OP RATINGS FOR TRANSVERSE AND LONGITUDINAL CRACKS
RASED ON VISUAL EXAMINATION (a) OPENING
tint Description Rating Description
3 Good, coarse surface texture. S Hairline or filled.
.5 Good, gritty surface texture. 4 1/16 to 1/8 in. open
4 Fair, coarse surface texture. 3 1/8 to 1/4 in. open
.5 Fair, gritty surface texture. 2 1/4 to 1/2 in. open
3 Aggregate slightly polished or wheelpath slightly darkened 1 More than 1/2 in. open
with excise asphalt.
2 Aggregate polished or wheelpath darker due to excess asphalt
1 Bleeding condition.
(b) CRACK ABRASION OR EROSION
S No wearing back of cracks.
4 Slight wearing of edges (mortar).
3 Some coarse aggregate eroding out,
2 Crack eroded back 1/2 way through the surface mix.
TABLE 6 1 Eroded more than 1/2 way through the surface mix.
RATINGS FOR LEVELS OF UNIFORMITY
Retina Description (c) MULTIPLICITY •
5 Good
3 No associated cracks.
4 Streaked 4 A few associated random hairline cracks.
3 Crack-filling
3 Map cracks developed, along with transverse and longitudina,
2 blotchy cracks.
1 Multiple Spot Patching 2 Alligator cracks developed, &long with transverse and longi-
tudinal cracks.
1 Multiple cracks have broken away from surface.
STREET CONDITION SURVEY
Date: ��3/K.?
ov// &P)
STREET Z 4✓ ( r � LENGTH
TERMINI — //c1/i77-QS — TO Lt
YEAR CONSTRUCTED LAST SEAL COAT LAST OVERLAY
STRUCTURE Type Thickness in G.E. Factor G.E.
Surface, (D1)
Base, (02)
Subbase, (D3)
TOTALS - - G•E•=
Laboratory
Embankment R-Value
Estimated
TRAFFIC Equivalent Loads (Z-N18)
AADT Since last O.L. or construction
Speed Future
5 yr. 10 yr. 20 yr.
CONDITIONS
Roadmeter
PSR < Uniformity
Panel
Surface Condition Crack Conditions
Structural 1' Opening
Abrasion Abrasion
Surface Wear
Bleeding !
Mult.
Weathering Rut Depth, in. /4 41 ot?
Number
Skid Resistance C TOTAL ,ck _ c, 5,,�=
Rating
SIDEWALK CONDITION :
SIGNS, UTILITIES
AND OTHER IMPROVEMENTS
DATE ,e —7-
TABLE 2 ,
f
,�j' DESCRIPTION OF GENERAL STRUCTURAL CONDITION RATINGS
STREET ,,,' .,; ';
Rating Description
ROM ✓))/1/ re) 2 TO V/ ✓ / s New pavement, good condition, no cracks.
4 Cracking beginning to develop as longitudinal
cracks in wheelpath.
3 Large pattern of cracks developed (map cracks).
$Y ✓✓✓ j 2 Pattern smeller (alligator creels),
1 Small pieces of pavement are thrown out by
traffic (erosion).
TABLE 3
TABLE 4
RATING FOR LEVELS OF PAVEMENT SURFACE WEAR
(a) ABRASION WITH NO SEAL COAT RATINGS FOR LEVELS OF WEATHERING
(a) PAVEMENTS WITH NO SEAL COAT
IllB.
-- •
Deacri tion
IES
Mat unifo n and original color acroes_a(irface, AIL
Bituminous surface original color stfiP t ..-^"--^t
path. possibly in vhee;
Coarse aggregate shows in wheelpath but not protruding.
Coarse aggregate shove in wheelpath and protrudes up to
1/16 in, or wheelpath`ig,.vorn down up to 1/16 i 4.0 Surface is color of rurfacr a�ggtegate, especially between
n.
whaelpaths.
Coarse aggregate protxudee in wheelpath more than 1/16 in.,
or mat is worn down more than 1114 in. 3.0 Coarse aggregate protrudes between wheelpaths.
More than 20 percent of coarse a �' 2.5 Random small cracks beginning to form, mostly between
the wheelpath. Bgregn�8-is. kicked out in
wheelpaths.
2.0 Random cracks developed into a pattern or blocks (not
related to loading),
(b) ABRASION WITH SEAL COAT 1.0 Coarse aggregate or chunks of surface being eroded out.
.111.1.11
Descri tion
5 Surface uniform original color of seal coat across the
surface.
4 Color lighter in wheelpath. (b) PAVEMENTS WITH A SEAL COAT OR SURFACE TREATMENT
3 Up to 25 percent of meal coat aggregate kicked out in
wheelpath.
Rating Description
2 Seal coat aggregate eroded away, shoving original surface
in the wheelpath. 5 Seal coat aggregate intact and in condition as constructed
1 Aggregate from original surface being kicked out in wheel- 4 Seal coat aggregate appears "drier" between wheelpaths (up
path. • to 10 percent eroded off).
3 10 percent up to 50 percent of seal coat aggregate eroded
off (both wheelpaths).
(c) ELEFMINC WITHOUT AND WITH SEAL COAT 2 Seal coat aggregate is more than 30 percent eroded off be-
tin tween wheelpaths, leaving only bituminous material coverin
Description the original surface.
Mat uniform and original color across surface. l./ Seal coat is essentially all eroded off and the original
5surface is beginning to erode.
1 Surface dark in wheelpath due to mix appearing richer in
wheelpath.
Bituminous material filling surface in wheelpath over 25 RUT DEPTH
percent of length.
Surface richer and bleeding somewhat along more than one-half
of the length in wheelpath. MAJOR MINOR NONE
Wheelpath rich and bleeding along entire length of pavement.
TABLE 5
TABLE /
RATINGS FOR LEVELS OF SKID RESISTANCE DESCRIPTIONS 0? RATINGS FOR TRANSVERSE AND LONGITUDINAL CRACKS
EASED ON VISUAL EXAMINATION
(a) OPENING
inY Description • Rating Description
Good, coarse surface texture. 5 Hairline or filled.
5 Good, gritty surface texture.
4 1/16 to 1/8 in. open
Fair, coarse surface texture.
3 1/8 to 1/4 in. open
5 Fair, gritty surface texture.
2 1/4 to 1/2 in. open
Aggregate slightly polished or wheelpath slightly darkened
with excess asphalt. More than 1/2 in. open
Aggregate polished or wheelpath darker due to excess asphalt
Bleeding condition.
(b) CRACK ABRASION OR EROSION
5 No wearing back of cracks.
4 Slight wearing of edges (mortar).
3 Some coarse aggregate eroding out.
2 Crack eroded back 1/2 way through the surface nix.
TABLE 6 1,' Eroded more than 1/2 way through the surface mix.
RATINGS FOR LEVELS OF UNIFORMITY
Rating Description (c) MULTIPLICITT •
5 Good
4 5 No associated cracks.
Streaked
4 A few associated random hairline cracks.
3 Crack-filling
3 Map cracks developed, along with transverse and longitudinal
2 Blotchy cracks.
1 Multiple Spot Patching 2 Alligator cracks developed, along with transverse and longi-
tudinal cracks.
r'
+1, Multiple cracks have broken away from surface.
STREET CONDITION SURVEY
Date:
STREET I IQr' ,r . / k LENGTH
TERMINI Ag '4" 0*4p TO
YEAR CONSTRUCTED LAST SEAL COAT LAST OVERLAY
STRUCTURE Type Thickness in G.E. Factor G.E.
Surface, (D1)
Base, (D2)
Subbase, (D3)
TOTALS - - G.E.=
Laboratory
Embankment R-Value
--<-77Estimated
TRAFFIC Equivalent Loads (ZN18)
AADT Since last O.L. or construction
Speed Future
5 yr. 10 yr. 20 yr.
CONDITIONS
Roadmeter
PSR Uniformity
Panel
Surface Condition Crack Conditions
Structural Opening
Abrasion Abrasion
Surface Wear
—(7-Bleeding
Mult.
Weathering Rut Depth, in. I 'aticip
Number
Skid Resistance cTOTAL �
Rating44' ' � �"
SIDEWALK CONDITION :
� I
l
SIGNS, UTILITIES
AND OTHER IMPROVEMENTS
DATE // i1 h/ :—
SA1LL 2
•
l • , DESCRIPTION OF GENERAL STRUCTULAL CONDITION RATINGS
STREET /
Rating Description
/.
S New pavement, good condition, no cracks.
'ROM ,/ ' ,.=, TO
. / � _ f
4 Cracking beginning to develop as longitudinal
cracks in wheelpath.
I
3 Large pattern of cracks developed (map cracks).
ElY 2 Pattern smaller (alligator cracks).
1 Small pieces of pavement ere thrown out by
traffic (erosion).
TABLE 3 TABLE 4
RATING FOR LEVELS OF PAVEMENT SURFACE WEAR RATINGS FOR LEVELS OF WEATHERING
(a) ABRASION WITH NO SEAL COAT (a) PAVEMENTS WITH NO SEAL COAT
Asa .Description
Rating Description
i Mat uniform and original eolo,Awaetos■ surface.
Coarse aggregate shows 1 •,Wheelpath but not protrudin 5.0 Bituminous surface original color except,•possibly in wheal
g. path.
Coarse aggregate sh ' in wheelpath and protrudes up to '
1/16 in. or vhee th 1 rn down up to 1/16 in. 4.0 Surface is color of surface aggregate, especially between
wheelpeths.
Coarse aggregate protrudes in wheelpath more than 1/16 in.,
or mat is worn down more than 1/16 in. 3•® Coarse aggregate protrudes between wheelpaths.
More than 20 percent of coarse aggregate is kicked out in 2.5 Random small cracks beginning to form, mostly between
the wheelpath. wheelpaths.
2.0 Random cracks developed into a pattern or blocks (not
related to loading).
---..-.- (b) ABRASION WITH SEAL COAT 1.0 Coarae aggregate or chunks of surface being eroded out.
aline Description
5 Surface uniform original color of seal coat across the
surface.
4 Color lighter in wheelpath. (b) PAVEMENTS WITH A SEAL COAT OR SURFACE TREATMENT
3 Up to 25 percent of seal coat aggregate kicked out in
w+aeelpath. Description
2 Seal coat aggregate eroded away, showing original surface
in the wheelpath. 5 Seal coat aggregate intact and in condition as constructs,
4 Seal coat aggregate appears "drier" between whaelpeths (ut
1,' Aggregate from original surface being kicked out in wheel- percent to 10 eroded off).
3 10 percent up to 50 percent of seal coat aggregate eroded
off (both wheelpeths).
(c) BLEEDING WITHOUT AND WITH SEAL COAT2 Seal coat aggregate is more than 50 percent eroded off be-
"` tveen wheelpaths, leaving only bituminous material coverir
,ting Description the original surface.
1 Seal coat is essentially all eroded off and the original
5 Mat uniform and original color across surface. surface is beginning to erode.
4 Surface dark in wheelpath due to mix appearing richer in
wheelpath. • RUT DEPTH
) Bituminous material filling surface in wheelpath over 25
percent of length.
Surface richer and bleeding somewhat along more than one-half
of the length in wheelpath. MAJOR MINOR NONE
Whselpath rich and bleeding along entire length of pavement.
TABLE 5 TABLE 7
RATINGS FOR LEVELS OF SKID RESISTANCE DESCRIPTIONS or RATINGS FOR TRANSVERSE AND LONGITUDINAL CRAM
BASM ON VISUAL ELAKINATION (a) OPENING
•
ties Description • Rating Description
5 Good, coarse surface texture. 5 Hairline or filled.
.5 Good, gritty surface texture. 4 1/16 to 1/8 in. open
4 Fair. coarse surface texture. 3 1/8 to 1/4 in. open
5 Fair. gritty surface texture. 2 1/4 to 1/2 in. open
3 Aggregate slightly polished or wheelpath slightly darkened 1 More than 1/2 in. open
with excess Asphalt.
2 Aggregate polished or wheelpath darker due to excess asphalt
1 Bleeding condition.
(b) CRACK ABRASION OR EROSION
5 No wearing back of cracks.
4 Slight wearing of edges (mortar).
3 Some coarse aggregate eroding out.
2 Crack eroded back 1/2 way through the surface mix.
TABLE 6 ( 1 i Eroded more than 1/2 way through the surface mix.
RATINGS FOR LEVELS OF UNIFORMITY
(c) MULTIPLICITY •
Rating Description
5 Good 5 So associated cracks.
4 Streaked 4 A few associated random hairline cracks.
3 Crack-filling 3 Map cracks developed, along with transverse and longitudina
2 Blotchy cracks.
1 Multiple Spot Patching 2 Alligator cracks developed, slug with transverse and longi-
tudinal cracks.
1 Multiple cracks have broken sway from surface.
, .
frf
STREET CONDITION SURVEY
Date:
STREET Af 1.}1( -I-5- ,,‘,) LENGTH
TERMINI /7,2 ,;(41A, TO Atfr/ /1_ e 42,
YEAR CONSTRUCTED LAST SEAL COAT LAST OVERLAY
STRUCTURE Type Thickness in G.E. Factor G.E.
Surface, (D1)
Base, (D2)
Subbase, (D3)
TOTALS - - G.E.=
Laboratory
Embankment R-Value
Estimated
TRAFFIC Equivalent Loads (IN18)
AADT Since last O.L. or construction
Speed Future
5 yr. 10 yr. 20 yr.
CONDITIONS
Roadmeter
PSR Uniformity
< Panel
Surface Condition Crack Conditions
Structural I Opening
Abrasion
Abrasion
K
Surface Wear 7
Bleeding (
Mult.
Weathering _
Rut Depth, in. iqcs cile
ki
Number
Skid Resistance / .._,
TOTAL
\ !, Rating
SIDEWALK CONDITION :
1
I
L______
------
I 7
.
SIGNS, UTILITIES
AND OTHER IMPROVEMENTS
DATE L�r 0 .2- TABLE 2
f
4)0DESCRIPTION OF GENERAL STRUCTURAL CONDITION RATINGSSTREET ,?"
1 ! �J' Rating. Description
;ROM _+f l/J! TO J 3 New Pavement, good condition, no cracks.
/ 4 Cracking beginning to develop as longitudinal
cracks in wheelpath,
Y / , 3 Large pattern of cracks developed (map cracks).
_ 2 Pattern smaller (alligator cracks).
1_, Small pieces of pavement are thrown out by
traffic (erosion).
TABLE 3
TAILS 4
RATING POR LEVELS or PAV1J NT sURPACg WEAR
(a) ABRASION WITH NO SEAL COAT R(a) PA FOR LEVELS OF WEATHERING
COAT(a) PAVEMENTS Win NO SEAL COAT
`ins ®escri tion .
SMat uniform and original color otiose surface. Rating Description
i Coarse aggregate shows in3.0 Bituminous surface original colormtxcs tpossibly
vlsaelpath but not protruding. p in wheel
1 Coarse aggregate shtass..,4avheelpath and protrudes up to path. t r
1/16 in. or wheelpath,di worn down upto 1/16 in. Surface is color of surfacere ate, especially 4.0B pe dally between
Coarse aggregate prOtrwdes in wheelpath more than 1/16 ia., whaelpachs.
or met is worn down more than 1/16 in. 3.0 Coarse aggregate protru¢4a between vhetlpaths.
More than 20 percent of coarse aggregate is kicked out in 2.5 Random small cracks biginniag�
to form, mostly between
the wheelpath. whealpathe.
2.0 Random cracks developed into a pattern or blocks (not
related to leading).
---- (b) ABRASION WITH SEAL COAT 1.0 Coarse aggregate or chunks of surface being eroded out.
t'-•- iA1 Description
5, Surface uniform original color of seal coat across the
surface.
4 Color lighter in wheelpath. (b) PAVEMENTS WITH A SEAL COAT OR SURFACE TREATMENT
3 Up to 25 percent of seal coat aggregate kicked out in
whaelpath. Rating
Description
2 Seal coat aggregate eroded away, shaving original surface
is the wheelpath. S Seal coat aggregate intact and in condition as constructed
1 Aggregate from original surface being kicked out in wheel- 4 Seal coat aggregate appears "drier" between wheelpaths (up
path. to 10 percent eroded off).
3 10 percent up to 50 percent of seal cost aggregate eroded
off (both wheelpachs).
(c) BLEEDING WITHOUT AND WITH SEAL COAT 2 ' Seal coat. aggregate is more than 50 percent eroded off be-
tveen wheelpeths, leaving only bituminous material covering
LSng Description the original surface.
5 list uniform and original color across surface. 1 Seal coat is essentially all eroded off and the original
surface is beginning to erode.
4 Surface dark in wheelpath due to mix appearing richer in
wheelpath.
1 Bituminous material filling surface in whealpath over 25 RUT DEPTH
percent of length.
Surface richer and bleeding somewhat along more than one-half
of the length in whaelpath. MAJOR MINOR NONE
Wheelpeth rich and bleeding along entire length of pavement.
TABLE 5
TABLE 2
RATINGS FOR LEVEL! OF SKID RESISTANCE DESCRIPTIONS OF RATINGS TOR TRANSVERSE AND LONGITUDINAL CRACKS
BASED ON VISUAL EXAMINATION (a) OPENING
•
—
Description Rating Description
Good, coarse surface texture. 5 Hairline or filled.
S Good, gritty surface texture. 4 1/16 to 1/8 in. open
Fair, coarse surface texture. 1 1/8 to 1/4 in. open
i Fair, gritty surface texture. 2 1/4 to 1/2 in. open
Aggregate slightly polished or whealpath slightly darkened ,-1—:, More than 1/2 in. open
with excess asphalt.
Aggregate polished or wheelpath darker due to excess asphalt
Bleeding condition.
(b) CRACK ABRASION OR EROSION
S No wearing back of cracks.
4 Slight wearing of edges (mortar).
3 Some coarse aggregate eroding out.
2 Crack eroded back 1/2 way through the surface mix.
TABLE 6 1 Eroded more than 1/2 vey through the surface mix.
RATINGS FOR LEVELS OF UNIFORMITY
Rating Description (c) MULTIPLICITY
S Good
S No associated cracks.
4 Streaked
4 A few associated random hairline cracks.
3 Crack-filling
3 Map cracks developed, along with transverse and longitudinal
2 Blotchy cracks.
1 Multiple Spot Patching 2 Alligator cracks developed, along with transverse and longi-
tudinal cracks.
6:1 Multiple cracks have broken sway from surface.
STREET CONDITION SURVEY
��
Oate: �/!�'Y;/72
STREET ./�°t/��r . LENGTH
~ // `
TERMINI 77TO
YEAR CONSTRUCTED LAST SEAL COAT LAST OVERLAY
STRUCTURE Type Thickness in G.E. Factor G.E.
Surface, ([� ]
1 —_—'
Base, (D2)
— --
Subbase, ([� )
3
TOTALS - - G . E.=
Laboratory
Embankment R-Value
^^~7 Estimated
TRAFFIC Equivalent Loads (11\118)
AADT Since last O.L. or construction
SpeedFuture
' ---- -
5 yr. 10 yr. 20 yr.
CONDITIONS
Roadmeter
PSR Uniformity
�� Panel
�
Surface Condition Crack Conditions
Structural Opening
Abrasion
Abrasion
Surface Wear
\ Bleeding
Mult.
Weathering Rut Depth, in. �� ''
' ���cxuz
Number
Skid FlesistanceTQTAL /-
«~ --> Rating `~~'` `"
"
/
�
.
SIDEWALK CONDITION :
/ \
_
| ' '
| !
SIGNS, UTILITIES
AND OTHER IMPROVEMENTS
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MEMO TO : John K. Anderson
City Administrator
FROM: H. R. Spurrier ,
- City Engineer
RE : 1982 Seal and Chip Progra
DATE : May 28, 1982
Introduction :
In 1981, City Council authorized the Engineering Department to perform a
pavement analysis in order to identify the streets to be included in the
1982 Seal Coat Program.
City staff has completed the preliminary analysis of the streets and the
results will be displayed on a map in City Council Chambers for the meeting
Tuesday.
The analysis indicated overall Shakopee streets are not unlike most of the
streets in• the rest of the Metropolitan area, in that they are wearing out
rapidly.
It was surprising to see such a large number of relatively new streets in
average condition. Some of these streets were less than eight years old and
already exhibited characteristics associated with streets nearly 20 years old.
Most of the problems seem to be related to poor sub-grade or inadequate
pavement structure. Inadequate pavement structure was sometimes the result
of streets receiving more traffic than the pavement structure could accommodate,
even 10th Avenue fell into this category.
Originally, the recommendation was to include approximately 4 miles of seal
and chip work. In reviewing the bid prices the City received on Valley
Industrial Boulevard South, it appeared that one extremely viable option had
been overlooked.
That option was the option of a structural overlay to increase pavement
strength whereby reducing the rate of which the pavement was wearing out.
In view of the fact, that seal and chip was going to cost between $0.85 and _ _ oq (`i
$0. 95, and a rubberized asphalt was going to cost between $1.60 and $2. 10,
the alternative of a structural overlay was more than competitive. f.eit,p44
As the map indicates, most of the problems occur in the older part of Shakopee.
Many of the streets in need of major restoration work are streets that would be
affected by the future Holmes Street Lateral Storm Sewer. The balance of
the streets are county roads, or lie outside that area„
John K. Anderson May 28, 1932
Seal & Chip Program - 1982 Page -2-
The remaining streets can be corrected in one of two ways, by reconstruction
or by a structural overlay.
A structural overlay would help 10th Avenue, Harrison and some of the side
streets. Many of the remaining streets have unacceptable sub-grade materials
and could= not be helped with an overlay. Reconstruction will be the only
alternative for these streets.
If 10th Avenue was overlaid, it would be the recommendation of City staff
that the drainage pans located across 10th Avenue be altered in order to
reduce the impact to a reasonable level for an automobile traveling 30 miles
per hour.
The concept of an overlay is different than the concept originally approved by
City Council in the 1982 budget. Therefore, it is the recommendtion of
City staff that the 1982 allocation for seal and chip program be reallocated to
a pavement overlay program.
The overlay program and concrete pan replacement would be performed with
the money originally allocated for the seal coat program.
The actual depth of the overlay would be determined by further analysis by
the Engineering Department.
Recommendation :
Direct the Engineering Department to prepare the necessary plans and
specifications for the bituminous overlay of 10th Avenue between County Road
17 and Harrison Street.
HRS/jiw
. j
CiTT`Op4,,IlI CITY OF SAINT PAUL
OFFICE OF THE CITY ATTORNEY
ul I Iltu
"'11°" ^c w EDWARD P. STARR, CITY ATTORNEY
N, „` , 647 City Hall, Saint Paul, Minnesota 55102
612-298-5121
GEORGE LATIMER 9a2
MAYOR MAY 2 4 1982
May 21, 1982
CITY OF StHAKOPEE
John Anderson
City Administrator
City of Shakopee
129 E. First Ave.
Shakopee, Mn. 55379
Dear John:
Enclosed you will find the material with which the City began
its efforts to register our employees with physical impairments .
I hope they prove to be of use to you.
If you have any more questions please feel free to call.
Sincerely,
THOMAS J. WEYANDT
Assistant City Attorney
TJW:gh
•
=r'o; CITY OF SAINT PAUL
=•s` OFFICE OF THE MAYOR
:
� .
y4 mum!
;.
11
%� = 347 CITY HALL
r-::.Fs SAINT PAUL MINNESOTA 55102
GEORGE LATIMER (612) 29g-4323
MAYOR
April 12 , 1982
TO: ALL CITY EMPLOYEES
FR: MAYOR GEORGE LATIMER
RE: REGISTRATION OF PHYSICAL IMPAIRMENTS WITH THE STATE
WORKERS ' COMPENSATION DIVISION
Many City employees face the problem of work-related
accidents . Any accident can have serious consequences for
both the employee and the City . While employee injuries can
be and have been minimized by safety precautions , we have also
been trying to minimize the impact of employee accidents on
our costs for Workers ' Compensation payments .
If an employee is injured at work , the City stands
ready to pay medical bills and time lost from work . In
1981 , the City received approximately 500 Workers ' Compensation claims .
These and past claims cost the City $1 , 600 ,000 in 1981 . As we look
for ways to trim the budget , that figure deserves our atten-
tion.
Now something can be done to limit the City ' s exposure
to some of these expenses . The Workers ' Compensation law
requires an employer to register an employee who suffers from
certain forms of physical impairments or previous injuries
(sustained either on or off the job) . This registration
allows the City to obtain reimbursement from the state if the
employee suffers a second injury while at work . The right
of the employee to collect Workers ' Compensation benefits is
not affected in any way by this law. He or she will maintain
the right to collect Workers ' Compensation benefits from the
City . The City will have a right to recoup some of these ex-
penses from a separate fund set up by the state . It is not re-
quired that the original cause of the impairment be caused by
any injury related to your employment; it is simply required
that we provide medical proof that the impairment exists .
All City Employees -2- April 12 , 1982
In order to maximize our ability to obtain reimburse-
ment, it is necessary that we have the registration completed
within certain time limits . To accomplish this I am asking
that each of you complete the attached forms and return them
to the timekeeper when you hand in your time card for the next
pay period. Or , if you prefer, for the sake of privacy, you
may return the questionnaire to John Devlin in charge of
Central Registration (please inform your timekeeper that you
are going through Devlin) . Please remember to return the
questionnaire on time.
If you indicate that you have an impairment , the city
will then contact your doctor to obtain the proper documentation
and file the necessary forms with the state for registration.
I am asking your cooperation in this effort. Again ,
I will stress that the impairment need not have been caused
by an accident at work , and that the registration process
will not have any negative impact upon your right to receive
Workers ' Compensation should you suffer an injury while working
for the city.
If you have any questions concerning this process , feel
free to contact Ed Vizard, 298-4221.
Attached find a description of your Workers ' Compensation
Program.
GL/lm
QUESTIONNAIRE TO CITY OF SAINT PAUL EMPLOYEES CONCERNING PHYSICAL IMPAIRMENTS
(Name)
(Address)
(Date of Birth)
Social Security Number)
I do do not have any of the physical impairments listed below:
(Circle any that apply to you. )
a. Physical impairments for which at least g. Residual disability from
50 weeks or more of weekly benefits would poliomyelitis
be payable if evaluated according to h. Cerebral Palsy
standards used in Workers' Compensation i. Multiple Sclerosis
proceedings. j . Parkinson' s Disease
(e.g. , 20o permanent partial disability of k. Cerebral vascular accident
the back, 30o permanent partial ,disability 1. Chronic Osteomyelitis•
of the right knee, missing kidney. ) m. Muscular Dystrophy
n. Thrombophlebitis
o. Brain tumors
p. Pott's Disease
q. Seizures
b. Diabetes r. Cancer of the bone
c. Hemophilia s. Leukemia
d. Cardiac Disease t. Epilepsy
e. Partial or entire absence of thumb,
finger, hand, foot, arm or leg.
f. Lack of sight in one or both eyes or
vision in either eye not correctable
to 20/40.
The doctor who routinely treated me for this condition is:
(Name)
(Address)
Employ`e ' s Signature: Date:
THIS PORTION IS TO BE COMPLETED BY ANY EMPLOYEE WHO INDICATES HE/SHE HAS ONE OF THE ABOVE.
LISTED IMPAIRMENTS.
I hereby authorize the above noted physician to release to the City of Saint Paul an•;'
reports relating to the above noted condition for the purpo-,t: of registering
my physical impairment with the State of Minnesota Workers' Compensation Division.
____ ____
(Signature) (Date) —--- — --- --
---
(over)
•
You are asked to fill out this form in order to allow
the City of Saint Paul to register with the State of
Minnesota Workers ' Compensation Division , in accordance
with MS 176 . 131 , any physical impairment you may have.
This will not affect your right to receive Workers '
Compensation benefits from the City of Saint Paul if you
suffer a work-related injury . You are required to fill
out this form, and if you refuse to fill it out completely
and accurately , you may be subject to disciplinary action.
These forms will be filed with the State of Minnesota and
access to these forms will be restricted to Personnel Office
staff and the Workers ' Compensation Division of the City
Attorney ' s Office .
If , for reasons of privacy, you wish to register directly
with Personnel , send this questionnaire to John Devlin ,
Room 265 City Hall , and inform your timekeeper of this .
CITY OF SAINT PAUL
^" OFFICE OF THE MAYOR
Rwiliut
347 CITY R aT
GEORGE LATIMER SAINT PALL,MINNESOTA 55102
MAYOR (812) 298-4323
RE:
The above noted individual is an employee of the City of Saint Paul,
who in a recent questionnaire indicated that he/she has the physical
impairment indicated on the enclosed questionnaire and release. This
impairment may be registerable with the Minnesota Department of Labor
and Industry . We would like your cooperation in making this
determination.
Using existing medical records, please complete the enclosed
"Registration of Physical Impairment" form and return it in the
enclosed envelope along with a copy of the latest medical report which
outlines the employee' s impairment in detail . If the impairment falls
within category "A", please assign a percentage of permanent partial
disability, using a recognized criteria such as the AMA Guidelines to
the Evaluation of Permanent Impairment.
If you have any questions about this matter, please feel free to
contact Assistant City Attorney Thomas J. Weyandt at 298-5121 .
Thank you.
Sincerely,
1. Application for registration under Chapter 589, Laws of 1971, shall be on forms prescribed by the
Workers' Cotnpensatiou Division and submitted in duplicate.
2. The following physical or mental conditions that are permanent in nature'may be registered.
a. Epilepsy. I. Chronic Osteomyelitis.
b. Diabetes. m. Muscular Dystrophy.
c. Hemophilia. n. Thrombophlebitis.
d. Cardiac Disease. o. Brain tumors.
e. Partial or entire absence of thumb, p. Pott's Disease.
finger, hand, foot, arm or leg. q. Seizures.
f. Lack of sight in one or both eyes or r. Cancer of the bone.
vision in either eye not correctable to s. Leukemia.
20/40. t. Other physical impairments for which
g. Residual disability from poliomyelitis. at least 50 weeks or more of weekly
h. Cerebral Palsy. benefits would be payable if evaluated
i. Multiple Sclerosis. according to standards used in work-
j. Parkinson's Disease. ers' compensation proceedings.
k. Cerebral vascular accident.
3. Medical evidence of the physical impairment shall be contained on the application or attached to
the application. Such evidence shall show the date of the last examination, the nature of the
impairment, the doctor's signature and the date of his signature. If not contained on the application, it
shall be a legible copy suitable for microfilming.
4. The application for registration with satisfactory medical evidence when accepted by the Division
shall be prima facie evidence of the existence of the named "Nature of Physical Impairment" shown
on the application, but shall not be determinative thereof, and the burden of proof upon this issue, if
contested at any time, shall be upon the party asserting its existence at the time of the subsequent
injury.
5. Should the Division deem the application unacceptable prior to the subsequent injury, the
applicant may, within 60 days following the receipt of notice of rejection, petition the Division in
writing for a hearing upon said application. A copy of said petition shall be served by the applicant
upon the State Treasurer, Custodian of the Special Compensation Fund, and upon the Attorney
General.
6. Upon receipt of said petition, the Division shall direct it to be heard by the Division, or assign it to
a compensation judge for hearing.
7. Hearings shall be conducted as provided by M_S. 176.411, with right of appeal.
8. Notice of Intention to Claim Reimbursement under Subd. 6 of this Chapter shall be on forms
prescribed by the Workers' Compensation Division and shall be filed within one year from employer's
first payment of compensation or medical expense. The Division may, upon proper showing, extend
such filing period.
Reimbursement shall be made by an order of the Division from the Special Compensation Fund on a
yearly basis upon application on Claim for Reimbursement forms prescribed by the Division. Such
application shall be verified, set out in detail expenditures made and expenditures for which
reimbursement is claimed, and shall be supported by medical reports showing the nature and extent of
disability and relationship to the injury and physical impairment for which reimbursement is claimed.
The employer shall file the original and one copy of Notice of Intention to Claim Reimbursement and
the Claim for Reimbursement with the Workers' Compensation Division showing proof of service upon
the Attorney General.
WORKERS' COMPENSATION DIVISION
DEPARTMENT OF LABOR AND INDUSTRY
444 Lafayette Road
St. Paul, Minnesota 55101
APPLICATION FOR REGISTRATION OF
PHYSICAL IMPAIRMENT
(See Directions on reverse side)
Name of employee or individual: Address:
Last First Middle
Social Security No.: Date of Birth:
•
Month Day Year
NATURE OF PHYSICAL IMPAIRMENT OR IMPAIRMENTS:
(see back of this sheet)
If this application is being filed by employer, give name and address of employer
MEDICAL EVIDENCE
1. Date of last examination
2. Nature of physical or mental condition that is permanent. (This must be one of the conditions
listed on reverse side. If condition (t), state percentage of disability to member; i.e. 20% of the
back; 50%of the leg,etc.)
3. Date of this report
Doctor's Signature
Doctor's Typed Name
WC/SF 500 (7/75)
Address
SUBMIT IN DUPLICATE