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Permits - Permit# SP-2021-00024 - 4469 Lafayette Lane - 3/17/2021City of Spring 30[ Park Permit CI rY OF l Permit Number: SP-2021-00024 Sl j N UPTA ��Issue Date: 3/17/2021 _ `_ _ _-K � _ �_ Zoning Type: RESIDENTIAL Use Type: IRC-1 To Schedule an Inspection Call: 952-442-7520 24 HOUR NOTICE REQUIRED FOR ALL INSPECTIONS • MON-FRI: 8AM-4:30PM • NO HOLIDAYS Details Site Address: 4469 LAFAYETTE LANE, SP, MN 55384 Description: Demo house down to foundation Permit Granted To: Homeowners Name: ROLAND GEORGE GROTH Phone Number: Parcel #: 1911723210058 Permit Type: BLDG - Demolition Permit Exp: 9/12/2021 Valuation: $30,000.00 Fees Receipt # Product Sale Date Quantity Date Paid Status Pmt Info Amount 11794 State Surcharge 3/16/2021 1.00 3/17/2021 Paid Check: 6187 $15.00 11794 Demolition 3/16/2021 1.00 3/17/2021 Paid Check:6187 $574.50 11794 Plan Review Fee 3/16/2021 1.00 3/17/2021 Paid Check: 6187 $373.42 Total: $962.92 Notes • This permit is issued in accordance with and subject to all provisions of Ordinances and policies governing building and zoning in City of Spring Park. • Permit Holder/Contractor/Owners Agent is responsible to call for the inspections! • Permit Packet, including approved plan, and this inspection record must be posted in an accessible location before calling for inspection. Maintain this inspection record until work is complete. • No deviations from the approved plans are allowed without prior consent from the building inspections department. • To Owner, Occupant, or Contractor: It is ILLEGAL TO OCCUPY this area/building until all required final inspections have been made, approved, signed, and certificate of occupancy issued! Scott Qualle, Building Official City of Spring Park +4349 Warren Avenue ♦ 55384 Copyright 02021 INSPECTION RECORD 2020 MN State Building Code 7" y City of Spring Park Permit Number: SP-2021-00024 Issue Date: 3/17/2021 SITE ADDRESS: 4469 LAFAYETTE LANE, SP, MN 55384 Description: PERMIT TYPE: BLDG - Demolition Demo house down to foundation ZONE/USE TYPE: RESIDENTIAL IRC-1 APPLICANT: S & S Demolition OWNER: ROLAND GEORGE GROTH No inspection will be performed, and a re -inspection fee will be charged, if this "Inspection Record", the "City of Spring Park Permit", and, when applicable, the approved plans are not available to the inspector. This permit expires if construction activity does not commence within 180 days from obtaining this permit; when construction activity has been suspended or abandoned for at least 180 days; or the work has not been inspected within 180 days from the last documented activity. IF SEPARATE PERMITS ARE REQUIRED, REFER TO THE "SEPARATE PERMITS REQUIRED FOR:" STAMP ON YOUR APPROVED PLANS/CONSTRUCTION DOCUMENTS TO IDENTIFY WHAT SEPARATE PERMITS ARE REQUIRED. ALL REQUIRED ROUGH -IN INSPECTIONS, NOTED ON SEPARATE PERMITS, MUST BE COMPLETED PRIOR TO SCHEDULING A FRAMING INSPECTION. ALL REQUIRED FINAL INSPECTIONS, NOTED ON SEPARATE PERMITS, MUST BE COMPLETED PRIOR TO SCHEDULING A BUILDING FINAL INSPECTION. DO NOT COVER ITEMS TO BE INSPECTED. Permit Card Inspection Inspector's Response Approval Date omments or Corrections Require Pre -Demo Required Demolition -. -. MUST CALL TO SCHEDULE NO LATER THAN THE BUSINESS DAY PRIOR TO THE INSPECTION DAY: 8:00 A.M. TO 4:30 P.M. MONDAY THRU FRIDAY. PHONE NUMBER TO CALL: 952-442-7520 When a Certificate of Occupancy is needed, return this card and the approved final inspection notice to the City of Spring Park office. CITY OF SPRING PARK PAGE 1 BUILDING PERMIT 4349 Warren Avenue SP-2021-00024 Spring Park, MN 66384 ❑ Handout Given Phone: 962-471-9061 Fax: 962-471-9160 ❑ Lead Handout Given Routed t MNSPECT _ UITE ADDRESS: _ I L. �' ��-- �— 1 t ff l� Lr ; t- C PID: -- _� 1) Was the home constructed before 1.978? (YES U, continue with line 2, NO &�ontinue without completing EPA Section) 2) Will the work disturb ?6 sq ft of interior painted surfaces or a20 sq ft of extenor painted surfaces? (YES o go to line 4. NO -if -fine 3) 3) Are there any windows being replaced? (YES ❑, go to line 4, NO.208ontmue without completing EPA Section) 4) Has this home been Certified Lead Free? (YES P. you MUST Attach Certification Information, NO : complete line 5) �) EPA Contractor Certification Ncrntler, NAT - (applies to contractor only) PROPERTY OWNER: -� �C �AN1Gi "•s'; � �� Address: r+ C ' N c {'C f k State: iT'tY Zip ,� �„' _ Errai' Ln I" Contact Name: : •i i Phone. ej 3 it CONTRACTOR: Sd-S eVI�O L! trr�l� Address: 700 /fni'1 er City: j or-e a State: MW Zip: - Phone: Fax: Contractor License No: L Z4 all La �I M015 Contact Name: c/e. Phone: Email: S C(NC� S CwiQ ci, roYWl ARCHITECT: Address: State- Zi : Phone: Fax: EmailContact Name: Phone: TYPE OF WORK: is New Construction Deck L-1 Re -Roof Commercial esidential o Change of Use : Pool Re -Side EST. VALUATION OF WORK a Finish Basement Retaining Wall Fence $ 31(".,(2c)12 .c'c' cRemodel cPorch ---- Shed Sduart feet, _ 0Addition emofilion c Window/Door Replacement Garage-AttachedlDetach ❑ o Plumbing-or(N4D oeWa on ?age;, # being replaced Detailed Description of Work: o Accesso Structure o Mechanical-vrov:de detat on Page 2 z Mlsc Other ir_Sh t1Glite dlc'ivic _ sgnanne of this eppilcatlon by the legal property owner or a licensed codractor. as the owners represenUtive, is required and Whortces the Zoning Administrator or designee and me Buildhng official v designee to enter upon the pmperty to perform needed Irtspectlons- Entry may be Wi ttoui prior notice. I hereby acknowtadga that I have read this application and state that all Itformelim is true and ronect to the beat of my knowledge. I Mther agree that at work performed will be in accordarce with approved plane, specifications and conditions and to abide by of ordinances of the Municipality rind the laws of the State of Minrmots regan*V octions taken pursuant to this permit I agree to pay all pion rwvrew fees even it I choose not to proceed with to worts. Pem;ti a)pires when work a It not commenced wtdttf 180 days from date of permit, or If wore is suspendea abandoned, or nor Inspected for 18D days. work beyond the scope of this permit, or work wtthW a permit or Inspection, wit be subject to a waxy. Noise Ordinance In Effect: MONDAY - FRIDAY Before 7 a.m. and after 10 p.m. Weekends/Holidays before 7 a.m. and after 8 p.m. SIGNATURE OF APPLICANT: �FF� N1 � DATE: .3 PRINTED NAME: S' e v This is the signature of: r or : - Owner's Representative OCCUP. TYPE: IRC-1 CONST. TYPE: N/A CODE: 2020 MRC BLDG SPRINKLED Yes VALUATION. $ 30,000.00 Permit Fee: $ 574.50 WAC Charge: $ Plan Review Fee: $ 373.42 Sewer & Water Hook -Up: $ State Surcharge: $ 15.00 Sewer & Water Disconnect: $ Site Inspection Fee: $ Water Meter. $ S.E.C. Fee: $ Muni SE/WA Fee: $ Investigation Fee / Other Fee: $ %° 7 : SAC Escrow. $2,4$5 Copy Charge ($.25 per 8-5 xi page) $ Other $ ZO License Check ($5) / Lead Check ($5) $ TOTAL DUE: $ to SUB -TOTAL $ 962.92 CommemM plans will be submttted to the Met council Environmental Svcs Plumbing Fee (from Page 2) $ W V for SAC deterfnklJllon. Escrow payment will be required when permit is issued, If Mechanical Fee from Page 2) $ after Met couna review no sAc is determined, escrow w HI be refunded in fta LL Special Conditions/Required Setbacks: O Building Approval By: ' DATE:03/15/2021 Printed Building Ap oval By: Nick Qualle X License Verification Cl Lead Verification - Checked By: N City Approval By DATE: Paid: Date: ,� — 0`l P �' Receipt No. [', i 61 By: Transaction ID: 11794 Transaction Number. Transaction Type: Payment Recipient: Contractor Notes: Thank you for your Payment! CI Uy M P k J N U"I'Ph"Al-_rt City of Spring Park 4349 Warren Avenue SP MN,55384 Ph:952-442-7520 $962.92 Date: 3/17/2021 Method: Check: 6187 Address: 4469 LAFAYETTE LANE, SP, MN 55384 Reference: Permit Number: SP-2021-00024 Type: BLDG - Demolition for Product: Status: Quantity: Price: Total Amount: Plan Review Fee Paid 00 State Surcharge Paid 1.00 Demolition Paid 1.00 $15.00 $15.00 $574.50 $574.50 Total Amount: $962.92 Page 1 of 1 Printed on: 3/17/2021 WINEIRMONE CITY OF SPRING PARK PAGE 1 BUILDING PERMIT 4349 Warren Avenue SP-2021-00024 Spring Park, MN 65384 ❑ Handout Given Phone: 952-471-9051 Fax: 952-471-9160 ❑ Lead Handout Given Ro d tp MNSPECT -a 1 817E ADDRESS: '1 L� LG4 t Ye it 1� t t i e- PID: 1) Was the home constructed before 1978? (YES U, continue with line 2, NO Ncontinue without completing EPA Section) a) Will the work disturb 26 sq It of interior painted surfaces or ZM sq ft of exterior painted surfaces? (YES ❑ go to line 4, NOji One 3) 8) Are there any windows being replaced? (YES o, go to line 4, NO b Fortfinue without completing EPA Section) <) Has this home been Certified Lead Free? (YES o, You MUST At Certification Information, NO ❑ complete line 5) 6) EPA Contractor Certification Number. NAT - (applies to corNractor onlY) PROPERTY OWNER O • F-; f PN Address: L1 Ci i{ hi c,r k State: )VIA/ zip:�i ` Ersai! � r•l>; rT� C'�1� .1 6)LLtsw - co '-I a Contact Name: ID it Gv" Phone: Z 2-0 •- 3 C ?,- CONTRACTOR; s4s e vM 0 itr l r ih Address: 70o /roN r r C : LprP✓ eJ State: MW Zi :STAr Phone: 4- G Fax: Contractor License No: C (�14 c7 Contact Nam: rJe Plane: �67 Ernal: .5 4►hol S eA40 cut. Cok" ARCHITECT'. Address: State: zip: Phone: Fax: tel: Contact Name: Phone: TYPE OF WORK: t: New Construction :1 Deck to Re -Roof -1 Commercial esidential ❑ Change of Use ❑ Pool ,_, Re-S(de EST. VALU/,ATION OF VMORK ❑ Finish Basement n Retaining Wall c Fence _ 30r, 00c) . e'G ❑ Remodel ❑ Porch ❑ Shed sousrer tact: „ t o Addition demolition n Window/Door Replacement t7" ❑ Garage-Attached/Detach a Plunbirrf}provee deal on ?ape? # being replaced DetsYad Description of Work; o Accessory Structure ❑ Mechanical -provide detaii on Page 2 ❑ Misc Other +tG`ser r reI N ;;,' 9 - $bMUn of MY applcaaon by the in" pmp" wsner or a fewmed canhactor. as the owners repreeaMsevs. Is required end sulhoraes Me Admtrrbha a de and the or deaignee to cuter upon the properly to pa Non needed trapeclions. Entry may be xitdiwrt prior notice. t hereby admor%deelp tied 1 have raw Wa and Metal4tee ion is true and covet to the beet d my knowledge. I archer agree that all work perforated we be in accordance weh approved peens, speteliuuone and conditions and to abide by all aNwences of Me Muniejiaay u and the taws of the state of Mkereofa regarding calms talan pumuam to Mie permit I agree to pry all plan review lees even it I rdwoe-not to proceed with the work PnnR expires when work h not conmemed wilt 180 days trom data orpowwK or r work Is unpended abandoned. or not Inspected tot 100 days. Wodc beyond the scope of Mis pemt. or work without a pamt or inspector, v111 be Subject to a penalty. Noise Ordinance, to Eflactt MONDAY - FRIDAY Before 7 am. and after 10 p.m. Weeiandsi lolidays before 7 a.m. and after 8 p.m. SIGNATURE OF APPLICANT: DATE:' PRINTED NAME: rev 1 of a tii This a the signature cif: r or ! . Owner's R entative OCCURTYPE: IRC-1 CONST. TYPE: CODE: 2020 MRC BLDG SPRINKLED Yes VALUATION. $ 30,000.00 Permit Fee: $ 574.50 WAC Charge: $ Plan Review Fee: $ 373.42 Sewer 8 Water Hook -lip: $ State Surcharge: $ 15.00 Sewer & Water Disconnect $ Site Inspection Fee: $ Water Meter. $ S.E.C. Fee: $ Muni SEANA Fee: $ Investigation Fee / Other Fee: $ `2016 SAC Escrow. $2,4a5 J Copy Charge ($25 per 8.5 x11 page) $ Other $ zo License Check ($5) / Lead Check ($5) S TOTAL DUE: $ W SUB -TOTAL S 962.92 tta Plumbing Fee (from Page 2) $ 'NOTE: ConalieW plans will be subaithd to the LM Council Emrironmentel Secs lu St for SAC deta mleallon. Escrow payment" be required when pan sR Is ksaai. lf Mechanical Feb from Page 2 $ alter Met Coued review no SAC Is dalarltiffted, escrow will be rehmded in eel, a Special Conditions/Required Setbacks: O Building Approval By: DATE:03/15/2021 Printed Building Approval By: Nick Qualle (K License verification ❑ Lead verification - Checked By: NQ City Approval By DATE: Paid: Date: Receipt No. By: CITY OF SPRING PARK PAGE 1 BUILDING PERMIT 4349 Warren Avenue Spring Park, MN 66384 ❑ Handout Given Routed to M�i SPECT Phone: 962-471-9061 Fax: 962-471-9160 El Lead Handout Given � ' 9 h k h e SITE ADDRESS: I L�Q ��y i 1 PID: 1) Was the home constructed before 1978? (YES ❑, continue with line 2, NO continue without completing EPA Section) 2) Will the work disturb Z6 sq ft of interior painted surfaces or Z20 sq ft of exterior painted surfaces? (YES ❑ go to line 4, NO)'line 3) • 3) Are there any windows being replaced? (YES ❑, go to line 4, NO�continue without completing EPA Section) 4) Has this home been Certified Lead Free? (YES ❑, you MUST Attach Certification Information, NO ❑ complete line 5) 5) EPA Contractor Certification Number. NAT - (applies to contractor only) • PROPERTY OWNER: Ap Ir')i Address: P0 v 3161 City: V (N ark state: MAI zip: 3 g Email: b tic r'D fi a. o-ts'y • co 1'"1 Contact Name: % 14 (-TV-() Phone: - Z 20 -_3 6 3- • CONTRACTOR: S<i's evvko t-I t"aY1 Address: 7q0o l�o)'1 cam/' ' rq ' City: L-oY(e ffe State: MA) Zip: IC-S--5- Phone: -. 416 f k Fax: Contractor License No: 1-ZC aJJ I a Contact Name: ' tCu e- Phone: '- 4_9 _66 Email: .5gKGk.5eyWQ Y 0, Covh ARCHITECT: Address: City: State: Zip: Phone: Fax: • Email: Contact Name: Phone: TYPE OF WORK: ❑ New Construction ❑ Deck ❑ Re -Roof ❑ Commercial esidential ❑ Change of Use ❑ Pool, ❑ Re -Side EST. VALUATION OF WORK ❑ Finish Basement a RetainkV Wall ❑ Fence $ ?jO� 000 . Oy ❑ Remodel ❑ Porch ❑ Shed Square feet: / ❑ Addition ,}demolition ❑ Window/Door Replacement b8 00 25 f rYL- ❑ Garage-AttachedlDelvich o Plumbing -provide detail on Page 2 # being replaced Detailed Description of Work: ❑ Accessory Structure ❑ Mechanical -provide detail on Page 2 ❑ Misc Other e m o If's hoote -F er- cram, �u v2 e j�. ah L Signature of this application by the legal property owner or a licensed contractor. as the owner's representative. Is required and authorizes the Zoning Administrator or designee and the Building Official or designee to enter upon the property to perform needed inspections. Entry may be rNlhout prior notice. I hereby acknowledge that I have read this application and state that all information is true and correct to the best of my knowledge. I further agree that all work performed will be In accordance with approved plans, specifications and conditions and to abide by all ordinances of the Municipality and the laws of the State of Minnesota regarding actions taken pursuant to this permit. I agree to pay all plan review fees even if I choose not to proceed with the work. Permit expires when work rr is not commenced within 180 days from date of psmilt, or if work is suspended. abandoned. or not inspected for 180 days. Work beyond the scope of this permit. or work without a permit or inspection. • will be subject to a penalty. Noise Ordinance In Effect: MONDAY - FRIDAY Before 7 a.m. and after 10 p.m. Weekends/Holidays before 7 a.m. and after 8 p.m. SIGNATURE OF APPLICANT: A 2 DATE: 3 -)A' -APRINTED NAME: P J e No tv This is the signature of: >rOwner or ❑ Owner's Representative OCCUR TYPE: CONST, TYPE: CODE: BLDG SPRINKLED Yes / No VALUATION: $ Permit Fee: $ WAC Charge: $ Plan Review Fee: $ Sewer & Water Hook -Up: $ State Surcharge: $ Sewer & Water Disconnect: $ Site Inspection Fee: $ Water Meter $ S.E.C. Fee: $ Muni SENVA Fee: $ Investigation Fee / Other Fee: $ *2016 SAC Escrow: $2485 J Copy Charge ($.25 per 8.5 x11 page) $ Other. $ Z License Check ($5) / Lead Check ($5) $ TOTAL DUE: $ to SUB -TOTAL $ NOTE: Commercial plans will be submitted to the Met Council Environmental Svcs Plumbing 9 Fee ( from Pa e 9 2 ) $ for SAC determination. Escrow payment will be required when permit is issued. If W Mechanical Fee from Page 2 $ after Met Council review no SAC is determined, escrow will be refunded in full. U ILL Special Conditions/Required Setbacks: IL O Building Approval By: DATE: Printed Building Approval By: ❑ License Verification ❑ Lead Verification - Checked By: City Approval By: DATE: Paid: Date: Receipt No. By: Checklist for Demolition Permit u�jII��4 / r MUST be included when applying for permit) Project Name: " l `[ b l �--ALzA 4 C 4e LR h e_ Date: 3` f -Olt Address: qq b� /,�-�Gi4 Q_ I' f 2 LCAK r? Municipality: S jorl nq 19rx rk Owner's Name: �U 4�i �� Telephone Number. Contractor's Name: S4 3 0 e 4K t) Telephone Number: ' b 6Ab Detailed explanation of work to be performed: r, . Yes No ❑ Will the demolition work disturb greater than one acre of land? Disturbed land includes: land used for stockpiling; land surrounding the structure that is to be demolished that will be altered during the final excavating work; the land where the removed structure was located; construction site entrance. IF YES: Separate Stormwater Pollution Prevention Plan (MPCA) and local MS4 requirements may apply. IF NO: Sediment and erosion control practices must be maintained. Have the following been submitted or completed? Y No N/A ❑ ❑ Completed permit application. ❑ ❑ Two sets of site plans verifying the location and size of structure(s) being demolished. ❑ ❑ Two sets of plans showing area of'interior/exterior demo work. ❑ ❑ A written description of building demolition method. �' ❑ ❑ A written verification and/or site plan identifying the type of pedestrian protection being provided, including description of type, location and height of fencing to be used. ❑ ❑ A performance bond, letter of credit, escrow or securities in accordance with Municipality ❑ ElA policy. Deolition/Renovation Notification submitted to the Minnesota Pollution Control Agency. m (Under Section 40-of the Code of Federal Regulations Part 61(M), if the structure is regulated, you must submit a Notice of Intent to Perform a Demolition. Single family ❑ dwellings are generally exempt.) All utilities properly terminated. ❑ ❑ All wells properly abandoned in accordance with State Health Department regulations. ❑ ❑ Septic tanks pumped and removed. ❑ ff ❑ Are there any underground storage tanks to be removed? ❑ ❑ All hazardous materials removed and disposed of in accordance with Minnesota Pollution Control Agency requirements. See the MPCA documents Pre-Renovation/Demolition Environmental Checklist and Pre -Renovation or Demolition Requirements (attached) for more information. Signed: Date: 3 ` 1 d Demolition (Structures) Han0out Page 2 of 9 Copyright m MNSPECT 2020, Rev. Nov 2020 Minnesota Pollution Pre -Renovation / Demolition Control Agency 520 Lafayette Road North Environmental Checklist St. Paul, MN 55155-4194 Asbestos Program Doc Type: Comptiance/Enforcement Correspondence Minn. R. 7035.0805 requires that you remove the items below before starting a renovation or demolition project, and then manage and recycle or dispose of them correctly. This checklist is provided to help you manage the project and does not need to be submitted to the Minnesota Pollution Control Agency unless requested. Project Information Structure owner J/Structure information ,[ f / Name: o Ja n A 6-ra +k Building name: Ae $1'd e kl l ' I e ul e Address: _ p (jpX f (p Address/Location: yL[(p City, State, Zip: S rl K Q V11 1r K ,IvW s y City, State, Zip: v 4P rr'nV !�� f K mN -.,- -N -5V It Contact name: BLA, &V6 rh Age of bldg (yrs): I cl— Size of bldg (sq ft): GD Phone number: S 0 Present use of bldg: Q W t?1 1 f�11 Demolition co tractor Prior use of bldg: NO,tJ Name: .S .5 De PK 40 fi'v r, Address: O U gheet a Dates of renovation, demolition, or fire training bum: City, State, Zip: Lore ?- Start date: 3 -IS a I End date: 3 --30 -oZ' Contact name: -S ✓e 5 - /t W (mm/dd/yy) (mm/ddryy) Phone number: � � - ;5-& - (o (o Mercury Oty Batteries Q Smoke detectors: Emergency lighting systems: O Elevator controlpanels: (� Exit signs: U Security systems and alarms: 0 Lighting Fluorescent lights: High intensity discharge Metal halide: (� High pressure sodium: Mercury vapor: Neon: Q Switches for lighting using mercury relays took for an O control associated with exterior or automated lighting systems): "Silent" wall switches: Heating, ventilating, and air conditioning systems O Thermostats: (� A uastats: Pressurestats: IE 0 J Pressure-trol: Q Float or level controls: d 0 0 Asbestos _ Boiler rooms b Oty Boiler insulation: d HVAC duct insulation: Ductwork flexible fabric connections: Fireproofing materials: Fire doors: Flooring: Vinyl floor tile: Vinyl sheet flooring: Asphalt tile: Linoleum paper backing: Mastic/glue (floor tile, carpet. etc.) D Electrical Electricalpanels: O Electrical wiring insulation: O Heating and electrical ducts/conduit: O Pipe and other insulation Aircell (corrugated cardboard): Millboard: Preform: Joint compound: www.pca.state.mn.us 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats w-sw4-20 • 7116109 Page 1 of 2 Demolition (Structures) Handout Page 5 of 9 Copyright 0 MNSPECT 2020, Rev. Nov 2020 Asbestos (continued) ow Spray applied insulation: O Blown -in insulation: 0 Block: Surfacing materials Acousticalplaster: 0 Decorativeplaster: Textured paints & coatings: Spray -applied materials 0 acoustical, decorative, or insulative : 0 Roofing Roofing shingles: Roofing felt: Base flashing: Cement materials ransite Cement pipes flues & vents): 0 Cement wallboard: 0 Cement siding: Pegboard: T- Coiling materials Ceiling titles: Ceiling tile adhesives (pucks): Lay -in ceiling panels: t� Acoustical tiles: Miscellaneous Taping, joint, andspackling compound: Caulking/putties: Fire curtains and blankets: Laboratory hoods, table tops, gloves, etc.: Gaskets: 2i ChloroFluoroCarbons Fire extinguishers both portable and installed halon suppression systems) 0 Air conditioners (rooftop, room, and central Walk in coolers (refrigeration or cold storage areas): Water fountains and o dehumidifiers: Refrigerators/freezers/chillers: 0 Heat pumps: 0 Vending machinestfood display cases: Poly -Chlorinated BiPhenyls (PCBs) Transformers: Transistors: O Ca acitors: G Heat transfer equipment: Light ballasts: Lead Gly Lead -acid batteries (lighting, exit O signs, security systems): d Lead flashing molds and i.J' roof vents: Lead pipes and solder: Lead -lined X-ray rooms: CT Other Solid waste all non -building components such as unattached carpet. files, books, trash, desks. 1 chairs, etc. must be removed prior to demolition: Hazardous waste(including household must be properly handled and disposed of prior to demolition. Oil used oil. hydraulic oils in door closers, elevator shafts, etc. must be collected and properly disposed of prior to demolition: 0 Tanks (no evidence of former heating tanks or storage tanks 0 exist Appliances must be recycled by an appliance recycler: Electronics: If you have questions or comments about this checklist, identify any additional items not found in this list, or would like to discuss an individual project, contact the Minnesota Pollution Control Agency at 651-296-6300 or 1-800-657-3864. Affiliation with project:` do h Title: OW ✓i& h S Printed name: Je SLre.(L6W Date: 3 - - /d -.2 Important Note: This guidance document is not intended as a substitute for reading Minnesota Rules and Statutes and making your own independent determination of their applicability to your renovationidemolition project. Examples in this guidance document do not represent an exhaustive listing of type of materials that may be required to be removed from a building prior to renovation/demolition. www.pca.state.mn.us 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats w-5w4-20 • 7116109 Page 2 of 2 Demolition (Structures) Handout Page 6 of 9 Copyright 0 MNSPECT 2020, Rev. Nov 2020 me,+tti14 Tr, A ct 1 I Sa-r a-,e Fe vi ( e I U PDT aL6cO►)frol CA it d A viJ L v d4 rj> �wu-k iv "mod C- I �, 5�a l I b(^U Lo)� i )r gyros" covl'vD, U� ►�l�' / 0. (4) Si+e la r,\ .� 0 �lG)y , h i L o C° I I �U c,j 191d Uo fV- d4a-d ` 1J+ Sa f )d .9�trr)�— Aoq ( W A//5 u4J ltloorS r444 e op Gpmed? _�s IZZA 17 JO d PIOW Sac,Q/i rn 61k�V Lade �14')J-7 �Sh uj Ing ant tv Jg i —1 m1 MINNESOTA POLLUTION Demolition/Renovation notification CONTROL AGENCY 520 1 afayette Road North Asbestos Program St. Paul, MN 55155-4194 Doc Type Asbestos 8 Demo/tion/Amendments Type of notification: Original ❑ Amended ❑ Project cancellation Notification must be postmarked or received ten (10) working days before demolition begins. See Item 5 for emergency demolitions. Both start and end dates should be amended in writing as necessary to reflect current project dates. Submittal: Notifications may be made electronically (preferred) or by paper copy. To submit this form electronically, save the form to your computer and send the form to the Minnesota Pollution Control Agency (MPCA) by using the submit button at the end of the form, or attach the form to an email message, using Demolition/Renovation notification as the subject line to asbestos.demolition.oca(&state.mn.us. To submit the form by paper copy, please mail to the Asbestos Program at the address above: or fax to 651-297-1438. If you have any questions, contact the MPCA Asbestos Coordinator Kit Grayson at 218-302-6627. Demolition contractor Name of firm or organization: -Si Q O I C Mailing address: (UV Y/ a e 7 ra f City: !N r a State: 64 A/ Contact: S%V e— f'N-e tJ JOW Phone: 'U3- %- 4&AEmail: -SQ)1 Building owner � I Name of owner: 0 Q Yl Mailing address: v D City: 5 Ar r K State: Contact: GLJL Phone: f 1V Building information Name of building: P- 5 j cue n-)q I Address/Location: /} Q YI Q City: 5 P 'VIA K State: Contact: rff YD 1 r\ Phone: Zip code: <:nYv1 � County: m rl 1'1 IN Zip code: -Z5' 3 e 4% Email: If 6,r I-0i J, 6 fat S N • C Age of building: rs Size of building: 4o r(-)O s .ft. Number of floors, including basement level(s): 3 Present use of building: .S r eDt Prior use of building: IV v A1 1` Dates of demolition or intentional burning Start date: 3 — !8 - a 1 End date: 3 aft °Z mrWddlyyyy mm/ddlWy Note: If the combined amount of Regulated Asbestos Containing Material (RACM) exceeds 260 linear feet. 160 square feet. or 35 cubic feet in the facility to be demolished, it must be removed by a licensed asbestos contractor prior to demolition. The State of MN -Notice of intent to perform an asbestos abatement project http nwww pca state mn usi1publicationsm-sw4-06 doc must be used to notify for the asbestos removal. Is nonfriable ACM present in the structure to be demolished? ❑ Yes t�(No Will nonfriable, ACM be present In the structure at the time of demolition? ❑ Yes RVo If Yes to both questions above. complete Items 1-9 If No to either question, complete Items 3-9 If ACM will be left in place indicate the amount of Category I and/or Category II nonfriable ACM left in place. Category I: Linear feet Square feet Cubic feet Category I nonfriable ACM means asbestos - containing packings, gaskets, resilient floor covering, and asphalt roofing products containing more than one percent asbestos. Category I nonfriable ACM Is not allowed to remain in place for demolition if it is in poor condition. Category II: Linear feet Square feet Cubic feet Category If nonfriable ACM means any material, excluding Category I nonfriable ACM, containing more than one percent Asbestos that, when dry, cannot be crumbled, pulverized, or reduced to a powder by hand pressure. Category II nonfriable ACM is not allowed to remain in place for demolition if it has a high probability of becoming crumbled, pulverized, or reduced to a powder during demolition, transport, or disposal (e.g., transite, cement, slate roofing). www.pca.state.mn.us 651-296.6300 800-657-3864 Use your preferred relay service Available in altemative formats w-sw4-21 • 8129117 Page 1 of 2 Demolition (Structures) Handout Page 3 of 9 Copyright© MNSPECT 2020, Rev. Nov 2020 2. Description and location of ACM remaining in place (including number of floors and rooms): No"0e 3. Company and/or individual that conducted the building inspection and the procedure used to determine the presence or absence of ACM (including analytic method): (Note: Prior to demolition all structures must be inspected by a licensed asbestos inspector who has been certified through the Minnesota Department of Health.) i✓o Ai e 4. Description of planned demolition and the spnecific� method(s) that will be used: I�� G (pIC aG \. , eJ .(Q, r r1 e C1( W L S) i f i �1,_ Gf'� 4 C �j r rt )e 1 W Ct tr c1 pQ L-4a d I t1 f v n l u i h P l— R l�tJ hCL i z' Lq I'd �\'( ( 5. If the demolition was ordered by a government agency, please Identify the agency and attach a copy of the order: Name: /1,4 Title: Authority: A/,r� Date of order (mm/dd/yy): �� Start date (mm/dd/yy): / V + Notification for an emergency demolition must be submitted as early as possible before demolition begins, but not later than the following working day. A demolition is considered an emergency only when the facility has been deemed structurally unsound and in danger of imminent collapse. If the structurally unsound building is known to contain any regulated ACM or is suspected to contain any regulated ACM, special procedures must be followed. If you are unaware of the special procedures, instructionsl regulations can be obtained by contacting the MPCA at the phone numbers listed below. Refer to 40 CFR 61.145(a)(3) for additional information. 6. Description of procedure to be followed in the event that unexpected RACM is found or Category II nonfriable ACM becomes crumbled, pulverized or reduced to powder: 7. Waste transporter information: Transporter name: Mailing address: City: State: Contact: Phone: Email: 8. Permitted waste disposal site information: 'see below for more information Landfill name: Zip code: Mailing address: City: State: Zip code: Contact: Phone: Email: 9. By typing my name below, 1 certify that the above information is correct and I am a bonafide representative of the demolition contractor or building owner and have authority to enter into agreements for my employer. Print name: Title: )e 'J ( s doc nent has been electronically signed) � _ Date: 2 J j Important Note: Ensure you are in compliance with Minn. R. 7035.0805 prior to the commencement of renovation/demolition. This rule requires that the following items be removed two days prior to demolition: mixed municipal solid waste; household hazardous waste; industrial or hazardous waste: waste tires; major appliances: items containing elemental mercury, Poly -Chlorinated BiPhenyls (PCBs), and chlorofluorocarbons (CFCs); oil; lead; electronics; and other prohibited items. See MPCA website at http:.www oca.state mn uslpublications;w-sw4-20 odf for a Pre-Renovation/Demolition Environmental Checklist Guidance Document to assist with completion of this rule. 'Demolition waste must be disposed of at a permitted solid waste facility. For other disposal option please contact the regional MPCA solid waste compliance/enforcement staff with any questions. www.pca.state.mn.us 651-296-6300 800-657.3864 Use your preferred relay service Available in alternative formats w-sw4-21 • 8129117 Page 2 of 2 Demolition (Structures) Handout Page 4 of 9 Copyright 0 MNSPECT 2020, Rev. Nov 2020