Loading...
Permits - Permit# 16-35 - 2478 Black Lake Road - 1/1/2016I • 1 Date Received at City Hall: Name: Address: -j `r b,jtrr—Tff_V Demolition Property Address: Type Of Structure: - j 7v L_ Approx Date To Begin: Utilities On Site: Check (✓) all that apply Application For Demolition Permit Permit #: City of Spring Park, Minnesota Telephone No.: (-o — z % O (p � ) �SiA^ 1AA.�r L Estimated Completion Date: Sewer >< Water Electric-� Cable Gas Telephone Note: It is the Owner's or Contractor's responsibility to contact GOPHER STATE ONE CALL at 1-800-252-1166 to notify of the disconnect and to mark any underground utilities on the property. Will Utilities Be Used For New Structure? .................. Yes_ i No Note: If water and sewer services are never to be reused, the property owner is responsible for abandoning services according to Minnesota State Plumbing Code and must be inspected by the City of Spring Park Public Works Department. Is There a Water Well On Site? .............. Is There An Underground Fuel Tank?......... Demolition Contractor: ................. Yes No.,X -1.............. Yes No U�// /�j- / Telephone No. �I Z ��� — 613 Z_ 3 Address: /n 2 e2 !r�% idiy /6 � c�-dn'. 'PL S / /0" 5' S // S 6 ry Liability Insurance Co._ Q;�/ 1P r 116 5 z -7 , _ f2 {i'C, Telephone No. Policy No: Policy Period From: To: Coverage And Limits: 3, tr7— Note: In the event that any ASBESTOS is present in the structure state appr oved pproved methods must be followed. I hereby declare that I am the owner of the prQperty or the demolition contractor of above described property. I agree to comply with all state regulations and all materials fro t ition will be taken to a state approved demolition dum site. All the foregoing information contained on this permit is a e Corr tement of my i nt,on�. Signed By Applic ��� / Date: Z l [�, The Following Section To Be Completed By City Officials Permit Approved By: Total Fee: Title: Receipt No: Date: Received by: The Following Section To Be Completed By Public Works / Operator Water Service............ Disconnected Abandoned Sealed Signed Sewer Service............ Disconnected Abandoned Sealed Signed Electrical Service ...... Disconnected Abandoned Gas Service ............... Disconnected Abandoned Removed Signed Removed Signed Page] of 2 All of the foregoing requests must be completed and signed -off PRIOR to the start of any demolition. The undersigned owner/contractor hereby agrees as follows: 1. The structure shall be kept enclosed and/or secured until such time as demolition is complete. 2. Demolition debris will be kept off adjoining property and/or the public rights -of -way unless specific, prior approval is obtained in writing for temporary use thereof. 3. Foundations shall be completely removed from the ground. 4. All demolition debris shall be completely disposed of off site in accordance with all applicable PCA requirements. 5. Water wells must be abandoned in accordance with the State Health Department regulations. 6. Inspection required when all debris has been removed — before backfilling. 7. Within five working days of superstructure removal, a final inspection shall be requested. The site shall be left clean and clear of all debris, with any excavation filled with earth level with the adjacent ground elevation (except when such excavation is to be used as part of a new building and such new building is actually under construction). 8. Septic systems must be abandoned per MN Rules Chapter 7080. All septic tanks must be pumped, crushed and filled with native soils. An inspection is required after the tanks are pumped and before the tanks are crushed and filled. 9. The undersigned owner shall and hereby does indemnify and hold harmless the City of Spring Park, its agents, employees and assigns from and against all claims, damages, losses or expenses, including attorney fees, against the City, its agents, employees and assigns arising out of or resulting from the demolition described herein as performed by the property owner, his employees, agents, subcontractors or assigns. The undersigned hereby applies to the City of Spring Park for issuance of a Demolition Permit, agrees to do all the work in a strict accordance with the ordinances of the City and the regulations of the State of Minnesota, and certifies that all statements ma e on this application are complete- rue and correct. Applicant's Signature Owner's Signature Approved By: Page 2 of 2 Poor Quality Document Disclaimer The original or copy of a document or page of a document presented at the time of digital scanning contained within this digital file may be of substandard quality for viewing, printing or faxing needs. ;, 4% Checklist for Demolition Permit MUST be Included- when applying for permit) Project Name: 24_1 y 3L-ACK- L-hit-L Quo Date: k-Q Address: 7- q Municipality-: S r r.,ti- V L Owner's Name: LIV GV ni- _C,"r Telephone Number: G )Z —Zr7 0 G2_t q Contractor's Name: f jowccS 6X Telephone Number: G t 2 — Z'l o - 6 Z-1 Lf Detailed explanation of work to be performed: T1 �Zw�.o %-t S44 c.,_1, 41A -QL To L-r?>h1O f j L Z- 1 f&O C 1=VtpM nc 7a f=t: w C£ t �.i CZIE V� c r Lc; 7 '� f b irc� � ► � i�a,J'C e:F e�'Y Yes No N/A Have the following been submitted or completed? !® ❑ El Completed permit application. 1 ❑ ❑ Two sets of site plans verifying the location and size of structure(s) being demolished. ,a ❑ ❑ Two sets of plans showing area of interior/exterior demo work. Ja ❑ ❑ 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. ❑ ❑ �P performance bond, letter of credit, escrow or securities in accordance with the Municipality policy. ❑ ❑ :a A Notification of Intent to Perform a Demolition submitted to the Minnesota Pollution Control Agency. (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.) 9- ❑ ❑ All utilities properly terminated. GFA ❑ ❑ All wells properly abandoned in accordance with State Health Department regulations. ❑ ❑ A- Septic tanks pumped and removed. ❑ ®' ❑ Are there any underground storage tanks to be removed? Sig ❑ ❑ 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 in atioh. Date: 7 /z:7 (Structures) Page 2 of 9 Revised May-2016