Permits - Permit# 10-17-06 - 2471 Black Lake Road - 1/1/2006Oct 17 06 11:33a Sue Baker 952-471-1166 P.1
CITY OF SPRING PARK
4349 WARREN AVENUE
SPRING PARK, MINNESOTA
952.471-9051
DEMOLITION PERMIT APPLICATION
FEE $40.00
OWNER G.. !S�UZ- I-&Lkt ,f DATE It - 17 ' 0p
ADDRESS y l: PHONE �(2 Weq
CONTRACTOR � -vY� 1` �`� L�'��� ��ry PONE
Location of proposed demolition: bla361,
STREET ADDRESS
PLAT PARCEL PID !�'
ZONING Res enfiC�\
TYPE OF BUILDING TO BE DEMOLISHED: �QIA.fn1r
SIGNATURE OF OWNER ,— &JI .I&
The following items must be disconnected and inspected before demolition can proceed
and permit will be issued:
WATER--- - I �1?i �017- S� SEWER
(This is the applicant's responsibility, not the City`s.)
CENTERPOINT ENERGY -"'."
DATE I�
XCEL ENERGY DATE
MEDIACOM V DATE 444 —
OWEST i/ DATE�`1�--�1P
U71UTY SUPERINTENDENT C.St( DATE
Post-W Fax Note 7671
Date
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1Tlasai9V0VvI{ 1 Va;%a%AVY VVJi«V• L'i�4i�MJ
iWlnntt►svta
Notification of Yntent to Perform a Demolition
Pollution Type of Notification: ( I Ortglnal I I Amended I I Project Cancellation
Cdpntrd
Agency
pemolition Contras t Hllilfte llnl°ormatilon:
Namc:oi�,i
ee,,
Address: Address/Locat'ton.3—A- a '
tMA
a
citY, State, Zips-1 K AA I I W 9I i
Contact Person:�iCl)
Phone Numbcr(s): i ,E
Handim Owner:
Nsaw. s x-(-
Rd —
city, State, z" LJ
Contact person
Phonc Number(s)_ _
City, State, zip.
p
co"tr- 1 1
Age of Dtdg. (years): Sizt of Bldg. (sq. ft.): i v
Number of Floors Including Bwament t.evd(s). - CA
Premat Use ofaldg.. -N�
Prior Lite of Bldg.: 4- `
!Dates when �m At liar inteatio , �ng
will fin & End It
Notification mast be postmarked or received ten (10) WORKING days
before demoldion begins. *See ite=#5 for emergency demolitions.
Both Beginning and Rodmg dates shooW he amended to writing as .
necessary to reflect current project dates.
If there Is >260 linear feet or >160 square feet of Regulated Asbestos -Containing Material (IiACM) in the building
to be demolished, it must be removed by a licensed asbestos twatractor prior to detrwlition. The State of MN -
Notice of Intent to Perform an Asbestos Abatement Project must be used to notify for the asbestos removal.
Is noubdable ACM present in ttte structure to be dell hihed ? Y)E;S I 1 NO
I:f YES oomplete items 1-9. If NO compkic itoms 3-9.
1. IF ACM, will be left in place for the demolition indicate the amount of Category I and/or Category ll nonlriable ACM left
in place.
Categ.I Linear Feet
Square Feek
Cubic Feet.
Category I nonfiiable ACM mews asbecos-contai ung pneWngs,
gaskets, resilient floor covering, and asphalt roofing products
contn mg mart than one percent ashestoa.
*Cftory I rtoafriable ACM Is not allowed to remain in place
for demontloa If ft is in poor t:otaditlon.
2. Description & Location of ACM rcrnahftg in place
q x qago F no
iNotiSeati n of Zatenl 119 P�o �on fvrm (� t.duc)
Categ. II O Linear Feet
Square rcet
Cubic Feet
CaleBory ft nontriable ACM means any material, excluding
CaregarY I nonfNablc ACM, containing more than one percent
-kA=tos that, when dry, wmrQt be ctuz6l4 pulverized, or
mWoed to a powder by head pressure.
*Category 11 aonfrtable ACM is not allowed to reraatn t>a plate
for demolidon Kit has a high probability atbecaming Humbled,
pulywhDed, or reduced to a powder during demolition, tramper t.
or dbpmL (ex'I'rawd% temeat, slate roo6tie)
floor f and room
X:b ' Is
Revised 04102
3. Company cantor inamaum inai c unuaeuaa sale ,a., mazer
presence or absence of ACM (tndadmg aRalyUC method): *Prior to dernolidota all brdldingslurrrst be itispectd by
Qtad Protrclio4 cY,�,�r�adtted iieacror. 'Q °'i p
lt r1..i= �n1'tioR�te. d\/10
4. 1Derx4il ion of
If the
Will
!&;t the agency and attaeb a copy of the
order: t
Name:Title: Authority.
Date of Omer (MI .D/Y) Date Ordered to Begin (M/DIY):
* Nodficatlen For as emetLey demobtiaa most be subm tted as early as possible before demolldon begins, but not later titan the
following wornog day. A demollilon b conNdered an estugmy ONLY when ae fac7ity has been deemed stradarauy uaeotmd and
in danger of tmadsumt collapse. if d w structurally unsound baildiat 4 known to cotalm any repletal ACM or k suspected to contain
any regobded ACM, speetat procedures MUST be followed. -11 you are =Marc of the spacial procedures, indMduostrogulatlons can
be' obtained by co nbwflog the MPCA at On addreaa er phone number rated below.
6., Description of procedure to be followed In the event that emexpected RACM is found or Cat. II nonfriable
CM beco qumbled, pulver lud o rednced to po n `
r�twV�i`\�,nY\ it; a I Gail ('�1�t�°\
���— - -
Transpcater Gen
Transp lurr'A
city, Sate, Zip:.
Phonc Number'
9. I certify that the above
contractor or building
Send to: Mmnesota Pollution
Is cornet and I
ave authority too
Regional l avim=ental Managt neat Division
5201.afayette load Not1h
St. Paul, MN 55155-4194
jtion'WaRarte jidsposidIlaformatlon:
Name:
AddmdLocation:
City, state, Zip:
Phone Numbw,
n a bona8de repre=tattve of the demolition
ter into a7,ents for my employer.
i P Date
For questions call:
651-296-6300
1-800-657-3864
PCB Removal InfortUatION PobmNoriaated bipheavls (PCBs) mast be removed from the building prior to demolition. PCBs
may be found In light barkwis, Rmall capacitors found to old appliances, and trwaaformer oils. For questions call the MPCA
ffmardow Waste (IM bmineas awiptance unU at 1-80b-657-3714.
PCB removoi name/addresa/phaao munbar:
PC8 receiver natnaladdreselphone nuwher:
Mercury R8810val Information Mercwy containing material munJm ramovad from the builVing prior to demolition.
Mercury containing materials may hwfude flaorescen4 metal /talid®, high pr mffe sodium, aeon, mercury vapor lamps, rnercwry
awitches, thermostat probes, manometers. and gages. For questions call tiro MPCU HW business assfstan.:e unto at 1-800-65 7-3 724.
Mercury remover name/addtesdpboneuumber: —
Maroary maiver nouWaddreadphone umber. __ --- -
ReMpranta/CFCs/SCFCs Recovery Information A cerLtJted technidart must recover refrigerants from refrigeration
get eipmmt and systems in the bugft prior to demolition- For questions call the CFC program at I-800►657-38d4.
Refrigerant recoverer name/adtfre shone number:_.. _
Refrigerant receiver nametaddrese/phone camber
g4ou union of Intent to Partiotm a Demolition farm (w-sw4.11,doc)
RevlAed 09M
�pRAIR�e
U.S. POSTAL SERVICE CERTIFICATE OF MAILING
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MAY BE USED FOR DOMESTIC AND INTERNATIONAL MAIL, DOES NOT
PROM E FOR INSURANCE —POSTMASTER
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Received From:
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One piece of ordinary mail addressed to:
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PS Form 3817, January 2001