Permits - Permit# 17-18 - 2494 Black Lake Road - 1/1/2017Municipality File
Demolition Requirements,
Residential Building Removal
Read All Attached Materials!
EVERY PERSON PERFORMING WORK
FOR WHICH THE CODE IS APPLICABLE, CONSTRUCTION EQUIPMENT AND
MUST COMPLY WITH THE CODE (MRC MATERIALS SHALL BE STORED AND
PLACED SO AS NOT TO ENDANGER THE
1300.0120, Subpart 14).
Post Address on Construction
Site, Visible from the Road (MSFC
505.1)
ACCESS TO ON -SITE FIRE
HYDRANTS SHALL BE MAINTAINED
(MSFC 508.5.4).
PORTABLE FIRE EXTINGUISHERS SHALL
BE INSTALLED IN ACCORDANCE WITH
THE MINNESOTA FIRE CODE AND AS
REQUIRED BY THE FIRE CHIEF
CONTACT GOPHER STATE ONE
PRIOR TO EXCAVATION (MN
Statute 21613.04, Subd. 1)
Waste Materials shall be removed in a
manner which prevents injury or
damage to persons, adjoining
properties, and public rights -of -way
(MRC 1305.3302.2).
The work of demolishing any
building shall not be commenced
until any required pedestrian
protection is in place (MRC
1305.3303.2)
SUBJECT TO CODE COMPLIANCE
DURING CONSTRUCTION
REVIEWED FOR CODE COMPLIANCE
BY & (\ DATE 'S\NL_1
PUBLIC, THE WORKERS, OR ADJOINING
PROPERTY FOR THE DURATION OF THE
CONSTRUCTION PROJECT (MRC
1305.3301.2).
Hazardous Materials and contents are to
be removed per MN Rule 7035.0805. All
materials removed must be properly
characterized, tested, managed, and
disposed of, reused, or recycled in
accordance with applicable standards.
WHERE A STRUCTURE HAS BEEN
DEMOLISHED OR REMOVED, THE VACANT LOT
SHALL BE FILLED AND MAINTAINED TO THE
EXISTING GRADE [MRC 1305.3303.41.
Any wells, septic systems, or
underground storage tanks must be
removed, abandoned, or filled as
allowed be MN Statute.
All utilities must be properly terminated
prior to starting demolition.
FOR ALL INSPECTIONS:
No -CALL 24 HOURS IN ADVANCE
►GIVE PERMIT NUMBER
a -I
(952) 442-7520
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.
CITY OF SPRING PARK
PAGE 1 BUILDING PERMIT
4349 Warren Avenue
a
Spring Park, MN 55384 ❑Handout Given
Phone: 952-471-9051 Fax: 952-471-9160 ❑Lead Handout Given
i-1
rri
G�.
SITE ADDRESS:2 g *% 4 9k A-r V-_ PID: DI' I+} -13- lir 00
3
1) Was the home constructed before 1978? (YES ❑, continue with line 2, NO o continue without completing EPA Section)
2) Will the work disturb Z6 sq ft of interior painted surfaces or 2:20 sq ft of exterior painted surfaces? (YES ❑ go to line 4, NO o line 3)
3) Are there any windows being replaced? (YES.o, go to line 4, NO o continue without completing EPA Section)
4) Has this home been Certified Lead Free? (YES o, you MUST Attach Certification Information, NO o complete line 5)
5) EPA Contractor Certification Number. NAT - (applies to contractor only)
PROPERTY OWNER: T Al L �, ddreSS:
city, State: Zip: Email
I.
Contact Name: Phone:
•
CONTRACTOR:. .'V_ aob LA L Address: ( A-IcX ST
City. -L A' State: N.,/.Zip: Phone: 17,-2S _q 1. Fax:
Contractor License No: G q 4 . Contact Name: Phone: {, 1 2S
Emall: hi A^E QSrt,vT.oup, c
ARCHITECT: Address:
City: w State: Zip: Phone: Fax:
•
Email: Contact Name: Phone:
TYPE OF WORK: o New Construction ❑ Deck o Re -Roof
❑ Commercial ❑ Residential . o Change of Use ❑ Pool o Re -Side
EST. VALUATION OF WORK a Finish Basement ❑ Retaining Wall o Fence
$ / 0 4 S-O ❑ Remodel ❑ Porch ❑ Shed
Square feet a Addition Demolition ❑ Window/boor Replacement
❑ Garage-Attached/Detach ❑ Plumbing -provide detail on Page 2 # being replaced
I•
Detailed Description of Work: o Accessory Structure ❑ Mechanical -provide detail on Page 2 ❑ Misc Other
•
—tee LLD
•
Ign Im of IHs applkakon by the legal property owner or a licensed contractor, as the owners representative, Is required and authorizes the Zoning Administrator or designee and the Building Official
designee to enter upon Ste property to perform needed inspections. Entry may be without. prior notice. I hereby acknowledge that I have read this appllradort and state that all Information is true and
correct to the hest of my knowledge. I fuMer agree that all work performed will be In accordance with approved plans, specifications and conditions and to abide by an ordinances of the Municipality
and the laws of the state of Minnesota regarding actions taken pursuant. to thispermiL I agree to pay all plan review teas aver if I choose not to proceed with the work Permit mires when work
n
is not commenced within 180 days from date of permit, or 11 work is suspended, abandoned, or not Inspected for 180 days. Work beyond the scope of this permit, at work without a pemdt or hnspecuon.
•
be subject to a penalty. -
Noise Ordinance In Effect: MONDAY - FRIDAY Befo a.m. and after 10 p.m. Weekends/Holidays before 7 a.m. and after 8 pan.
SIGNATURE OF APPLICANT: DATE:. t `•
BOUNDARY AND TOPOGRPHIC SURVEY FOR
JIM PAUL
IN LOTS 5 & 6, SKARP & LINDQUISTS ROSE HILL
HENNEPIN COUNTY, MINNESOTAn
E X C E P 7 1 O Ar .1
EXCEP7yOH
6 :Wear
r
co
oy
0
LEGAL DESMPLL011 OF PREMISES SURVEI'f3
An of Lot S. and tM pm of Ld 4 SkMP and Undgdla[a Roan HOAtldllon,
ea of In,a aeaa0ed as 1o9oaa:
C�mnmex�n� pan Sie wh BrA of oW Loi&nz p*i82fed~aTWl
mmeaL Ogre at dpFa 6pM to ■ twin 36 het SoWt of9m NoM M of t
6e M m Bm pohn of CegiMnp. Bomar al aid lak fhanos We.�r1
Alm ameal emiaad of Lot9 eommendm at a oe9R In the NoM Ina of a
faw.rt
aMdme
t2c+INsD �a.L1�F
y To fH eutli It {t-
za
NaM B'm amid List emme In ■ WbdmVdkocdonhom aatd Pohd abnp • Bna •>mndtl tmm
ed�dnpPam md.pm NWr�t mrror dlaYd Lot b a Weaergr 0a d Wd 1+R diww NadMM
\/
YOandd flem�nNdiBnMs.l m�mt al tald Lat tlmnm E.WMionB tMe NaM
HARDCOVER
hm $weed
Thla inveyaMntir twu°Midnw mpo�Pply 1100 abomm dedd P V", and t w
PROPOSED CALL.CULATNONS
IooaBan Oran aNatlnp lioam. pompe. and ip—tresspm om mi dm popsad bodon
EXISTING LOT 27739�-BF.
of a popmed Immm.Oend� and ddva•ay. adore not pnp to l mw pry alher Bt�to+►
orMmadmiMaa.
PROPOSED 2992w S.F.
ORNE �-
PROPOSED WtNEWAY 2371
• tmn __
PROPOSED PORCH 2"-
Edadlp OLVmff Ene pidraeFntRlwLOO�lAlmatELT,Y61iY)
PROPOSED WALL lse+
. Pmpaaademi Rm oey,. 1p 2f1 40 UMFU M :Ws®:
Aopomd.W bvaftn � �� I � .@a
TOTAL 5903-SF.
1 I� 7a►Rflpla •amsstm
W83��21A9X
SCALE PI FEET
GRONSERG 3 ASSOCIATES, INC.
...,...:i..�
*+
taro.etatLOWARIIA
a4a
LWam.tewotasmm
MBiL watoY9twvE LONO LAff$L01 9S3Sd
CHECKLIST FOR DEMOLITION PERMIT
Project Name: PAUL - t f Date: S. 14.1
Address: 2a R 4- 8� L R-0 _City: Qom'
Owner's Name:. �1`% M NA& - Telephone Number: Co 12- 25 I -01113
Contractor's Name: ,if ttizrzn I.I,L, Telephone Number:
Detailed explanation of work to be performed:
TZ•rE Ianyl ; -
Has the following been provided or completed
Y No NIA
❑ ❑ Completed permit application submitted to the Municipality.
[� ❑ ❑ Two sets of site plans verifying the location and size of structure(s) being
demolished.
❑ ❑ Two sets of plans showing area of interior demo work. Cc^ 1LM
[( ❑ ❑ Written verification and/or site plan identifying the type of pedestrian
protection being provided. Describe type, location and height of S1 L F� NL�
fencing to be used.
❑ ❑ Have all utilities have been property terminated.
❑ ❑ [." Has a "Notification of Intent to Perform a Demolition" (not'tequrred'far
single family dwellings) been submitted to the Minnesota Pollution
Control Agency.
❑ ❑ [ Have all wells been properly abandoned in accordance with State
Health Department regulations.
❑ ❑ [vj� Septic tanks pumped and removed.
[►� ❑ ❑ Written description of building demolition method provided. p;,n o� gy Ekc4vR-v/z--
❑ 2" 0 Are there any underground storage tanks to be removed.
❑ ❑ ❑ Performance bond, letter of credit, escrow or securities provided
in accordance with the Municipality policy.
Q/" ❑ ❑ Have afl Hazardous m erials been removed and disposed of in
ac:co ance with the nnesota Pollution Control Agency.
Signed: Date: . 1
September 14, 2 47 6molition Page 2 of 2
To:
Stonewood
Attn: Nate
153 E Lake St
Wayzata, Mn,55319
Re: Letter of Completion
BERGOINC ENVIRONMENTAL
Date: 4/ 15/ 17
This is your formal notification that the following asbestos materials have been removed from
2496 Black Lake Rd in Spring Park:
- 350 SF of 9x9 floor tile in basement
- 252 SF of sprayed on ceiling material in the living room
We sealed off the areas of containment and installed a HEPA machine. The asbestos materials were
removed using approved engineered wet methods. All materials were bagged and manifested to a
certified asbestos landfill. Suits and respirators were worn by the workers while performing the work.
Thank you,
Blair Bollig
(C) 612-812-6791
4413 CRAWFORD RD (952) 920-8938
HOPKINS, MN 55343 BERGO.ENV@GMAIL.COM
Asbestos Survey and Building
Inspection Report,
2496 Black Lake Road
Spring Park, MN
For
Stonewood
Wayzata, MN 55391
Date
March 31, 2017
Hickey Consultants
Health and Safety Services
Hickey Consultants Occupational Health and 4301 Spruce Way
Environmental Safety Maple Plain, MN 55359
763-479-3214 phone/fax
Hickey Consultants Dhickeymn@yahoo.com
March 31, 2017
Nate Mitchell
Stonewood
153 East Lake Street
Wayzata, MN 55391
Office: 612-251-9713
Mobile: 612-251-9713
Fax: 952-697-5591
nate@stonewood.com
Dear Nate,
This letter and attached documentation reports the results of the Asbestos Inspection and Bulk
sampling performed by Hickey Consultants, in the building located 2496 Black Lake Road, Spring
Park, MN.
This study is significant in that it identifies asbestos -containing materials and provides guidance
regarding the relative location. When a building will have demolition of structural supports, the
MPCA (Minnesota Pollution Control Agency) requires that the friable asbestos, Freon, PCB and all,
mercury materials be removed prior to demolition of the structure.
U13
Building inspections, accompanied by bulk sampling of suspect asbestos -containing materials
(ACM), was conducted at 2496 Black Lake Road in Spring Park, MN. Hickey Consultants
performed the inspection. The ACM inspection covered all areas of the building. The building was
a 1-story home with a basement, attic and garage with approximately a 920-square foot structure
estimated to be built around the 1930's.
Asbestos containing materials >1% were found in two of the building materials. Building materials
sampled included vermiculite insulation, roofing shingles, tar paper, sheet rock walls, sprayed on
ceiling material, floor tile, plaster walls, caulk, window glazing, stucco, flooring paper and linoleum
flooring. Twenty-seven PLM bulk samples were collected during the building inspection and
analyzed for asbestos. ACM is considered positive with indicating levels of greater than one percent
(> 1 %).
The samples were analyzed and asbestos >1% was detected in the textured ceiling in the living
room. The ceiling texture is friable and should be removed prior to demolition. Asbestos >1% was
also found in the 9"9" orange floor tiles in the basement. The orange floor tile is non -friable and in
good condition, it will not be required to be removed prior to demolition if the demolition landfill
will accept asbestos floor tile in the demolition debris.
Asbestos <1% was found in the vermiculite ceiling insulation. It is not considered asbestos
containing if it contains asbestos <1 % and it does not have to be removed.
If the home is to be burned during fire training, then all asbestos will need to be removed by an
asbestos abatement company licensed by the state of Minnesota prior to demolition.
If the home is being torn down, then the asbestos floor tile and sprayed on ceiling texture can
remain per the Minnesota Department of Health. But you should check with the Demolition Landfill
you will be using first to make sure they will accept Demolition Waste with asbestos floor tile and
asbestos ceiling texture in it. Its best practice to use water and wet the house debris to keep the dust
down during demolition, especially when there is asbestos materials in the debris.
The MPCA Demolition notification (attached) must be sent in 10 days prior to demolition.
The thennostats and fluorescent light bulbs must be removed and disposed of properly because of
the mercury concern. The smoke detectors need to be removed because of radiation concerns. The
water heater, water softener, air conditioner, gas furnace, kitchen appliances (oven and
refridgerator), washer and dryer needs to be removed prior to demolition.
Current Environmental Protection Agency (EPA) statutes mandate control measures for friable
(easily pulverized) asbestos -containing materials. Non -friable materials (for example, tar paper, or
floor tile or mastic) do not pose an immediate exposure risk unless they are cut, torn, sanded or
otherwise abraded. Because non -friable materials have the potential to become friable during
certain activities, friable or non -friable materials have been identified in this building.
EPA's Asbestos Hazard Emergency Response Act (AHERA) was used as a guidance document for
bulk sampling procedures, sample analysis, and location selection. An AHERA asbestos trained
building inspector participated in the building inspection.
BULK SAMPLING METHODS
Asbestos bulk sampling was performed, sampling included collection of material samples and
analysis of bulk samples for asbestos percentages utilizing polarized light microscopy (PLM).
A walk-through survey of the building was first conducted to identify homogeneous areas and
develop a bulk sampling and inspection strategy. For each homogeneous area sampled, two criteria
were used to determine sample locations:
1) The sample site must be representative of the homogeneous area,
2) A random element to prevent bias from entering the results was exercised in sample site
selection.
Sampling protocol was as follows. Amended water consisting of water and a surfactant (soap
solution) was misted on the sample site before, during and after the sampling process. This served
to minimize dispersion of the sampled material. Sampling instruments were used to section a
representative sample of material away from building component. Sealed, plastic packs were used
to contain the sample and marked with the sample serial number. Sampling instruments were
cleaned after collecting each sample to prevent cross contamination of subsequent samples.
Inspectors utilized half -face respirators when appropriate, and gloves for adequate personal
protection during sampling activities.
Results for bulk samples collected during the survey are provided in the Asbestos Laboratory
reports attached by: EMSL Analytical, Inc. Bulk samples were analyzed by: EMSL Analytical,
Inc. 14375 23`d Avenue North, Minneapolis, Minnesota, utilizing polarized light microscopy
recommended by method EPA/600/R-93/116 in accordance with federal, state and local laws and
regulations. EMSL Analytical, Inc. National Voluntary Laboratory Accreditation Program
(NVLAP) number is 200019-0.
Attached are sample sheets describing; asbestos locations and the Demolition permit for the
Minnesota Pollution Control Agency. Complete laboratory analysis charts are also included in this
report.
If the homeowner was to remove the asbestos, they should wear personal protective equipment;
include a N-100 respirator and disposable clothing. The materials kept wet, and, check with the
landfill used for disposal to see if they allow asbestos containing materials.
Two landfills that take asbestos materials include: Rolling Hills Landfill in Buffalo and the Elk
River landfill in Elk River. Landfills that take demolition debris are Dem-Con landfill in Shakopee.
For more landfills accepting asbestos follow the link below.
https://www.pca.state.mn.us/sites/default/files/w-sw6-OO.pdf
If anyone is hired to remove the asbestos, they must be a Licensed Minnesota Department of Health
Asbestos Contractor. A current list of asbestos abatement contractors can be obtained from the
(MDH) Minnesota Department of Health -Asbestos unit at 651-215-0900. Or at the following MDH
website.
http://www.health.state.mn.us/divs/eh/asbestos/find contractor/asbestos contractor report.cfr?regio
n code=ME
A homeowner can legally remove the asbestos from their own home. However, safety
precautions need to be taken.
The Minnesota Department of Health has put together a how to list for safely removing asbestos
from your home. The website covers the following topics: Can I remove asbestos flooring
myself? What tools do I need? How do I prepare the work area? How do I remove it? How do I.
clean-up? And how do I dispose of the waste? It also includes guidance photos that illustrate
how to remove asbestos.
All of this information can be found online by going to the Minnesota Department of Health
website and searching for asbestos. It can also be found by following the link below:
http://www.health.state.mn.us/d ivs/eh/asbestos/floorti le/index.html#res
Some more good information on asbestos for the homeowner can be found at the following
intemet address: http://www.health.state.mn.us/divs/eh/asbestosihomeowner/index.htm]
(click on the above link while holding down to ctrl key to go to the links)
The fluorescent lights, ballasts, appliances, batteries, and thermostats can be taken to the Hennepin
County hazardous waste disposal site at 8100 Jefferson highway, Brooklyn Park, or 1400 West 96th
Street in Bloomington. Hennepin country recycle phone number is 612-348-3777 or go to
www.hennepin.us
If you have any questions or concerns regarding the information in this report, please contact
Hickey Consultants at your convenience.
Sincerely,
(, GS
o�Hickey MI . CSP.
Certified Industrial H enist
Safety and Health Consultant
ABIH No. 5741. BCSP No. l 1675
•.•'ep�f�D OF byn,
• l ;
�* �ooavoR�rE.
CERTIFICATION
NUMBER ••, �1
5741 CP
~ EMPIRES
c) 6-1-200
•••r� FDWARD N\G�'.�•��
Minnesota Department of Health Asbestos Inspector License Number AI2420
Attachments/Enclosures:
• Asbestos Inspection Survey Results
• Minnesota Pollution Control Agency Notification of Intent to Perform a Demolition
• Minnesota Pollution Control Agency Pre -Renovation or Demolition Requirements
• Hennepin County Recycling Drop-off Facility Locations
• Minnesota Department of Natural Resources Fire Burn Application
• Photo Log
• Sample EMSL Lab Results
• Floor Plan Maps
• Asbestos Inspector Certificate
Tmnectinn Data Sheet
Contains
Room/Area
Material
Asbestos
Estimated
Physical
Friable
Sample
Percent
Location
Description
>1%
Amount
Units
Condition
es/no
Number
Asbestos
Comments
VM1-01
<1%Actinolite
VM1-02
<1%Actinolite
VM1-03
None Detected
VM1-Vermiculite
VM1-04
None Detected
Attic of House
Ceiling Insulation
No
480
S ft
Good
Yes
VM 1-05
<1 % Actinolite
RM 1- Orange
speckled roofing
Exterior of House
material
No
920
S ft
Damaged
No
RM1-06
None Detected
TP1-Tar Paper
under house
Exterior of House
shingles
No
920
S ft
Damaged
No
T1-07
None Detected
CM2-Black caulk
Exterior of House
at base of house
No
528
S ft
Damaged
No
CM2-09
None Detected
CM3- White
Exterior of House
window glazing
No
12.5
S ft
Damaged
Yes
CM3-10
None Detected
CM4-11-
None Detected
Brown Layer
CM4- Brown
CM4-11-
None Detected
Exterior of House
window glazing
No
12.5
S ft
Damaged
Yes
White Layer
TP2-Tar paper
Exterior of House
under cedar siding
No
1320
S ft
Good
No
TP2-12
None Detected
RM2- Green
Speckled roofing
Exterior of Garage
material
No
484
S ft
Good
No
RM2-13
None Detected
TP3- Tar paper
Exterior of Garage
under roofing
No
484
S ft
Good
No
TP3-14
None Detected
Exterior of Garage
CM5-Grey window
Windows
glazing
No
48
S ft
Damaged
Yes
CM5-15
None Detected
SM1- Stucco
Exterior of Garage
siding
No
S ft
Good
No
SMI-16
None Detected
PC 1-Plaster
Interior of Garage
Ceiling
No
S ft
Good
No
PCI-17
None Detected
Contains
Room/Area
Material
Asbestos
Estimated
Physical
Friable
Sample
Percent
Location
Description
>1%
Amount
Units
Condition
es/no
Number
Asbestos
Comments
FT1- Linoleum
Kitchen
flooring
No
72
S ft
Good
No
FT1-18
None Detected
SM 1-Sprayed on
Living Room
ceiling material
Yes
252
S ft
Good
Yes
SM1-19
3% Chrysotile
SR1-20-
None Detected
Plaster
SR1- Sheet rock
SR1-20-Skim
None Detected
2nd Living Room
walls
No
S ft
Good
Yes
Coat
FT2-21-Floor
5% Chrysotile
Tile
FT2-21-Black
None Detected
Mastic
FT2-Floor tile,
FT2-21-Tan
None Detected
Basement
orange
Yes
350
S ft
Damaged
No
Mastic
FT3-22-
None Detected
FT3-Speckled
Linoleum
linoleum, 2"d layer,
FT3-22-
None Detected
Kitchen
floor tile
No
72
S ft
Damaged
Yes
Mastic
TP4-Paper under
1" floor of house
flooring
No
S ft
Good
Yes
TP4-23
None Detected
No
S ft
Good
No
None Detected
Material Descriptions
Contains Asbestos
Name
Description
>1%
VM 1
Vermiculite attic insulation
None Detected
None Detected
RM I
Roof of house, shingles
None Detected
TP1
Roof of house, tar paper under house shingles
None Detected
CM2
Black caulk at base of house
None Detected
CM3
White window glazing
None Detected
CM4
Brown window glazing
None Detected
TP2
Tar paper under cedar siding
None Detected
RM2
Garage roofing shingles
None Detected
TP3
Tar paper under garage roofing
None Detected
CM5
Garage window glazing
None Detected
SM I
Garage cement stucco wall
None Detected
PC 1
Garage plaster ceiling
None Detected
FTl
Kitchen and Dining room linoleum flooring
3% Chrysotile
SMI
Livingroom sprayed on ceiling texture
None Detected
SRI
Sheet rock wall board
5% Chrysotile
FT2
Basement floor tile 9"x9"
None Detected
FT2b
Basement floor tile mastic
None Detected
FT3
Speckled linoleum flooring
None Detected
TP4
Paper under flooring
Inspection Data Hazardous Materials Summary
Room/Area Location
Materials to be Removed Prior to Demolition
Comments
Air Conditioner, tires, possible oil tank in ground
Freon
Exterior of House
near chimney outside.
Concerns, oil
Radiation
Concerns,
Smoke Alarms, florescent lights, well to be sealed in
PCB
Interior of House
basement.(Water Well currently Not Sealed
Concerns
Mercury and
Florescent Light Bulbs, 2 cans of paint, Heatng oil
PCB
Garage
tank in the back of the garage
Concerns
Mercury
I" Floor
Thermostat
Concerns
hot water heater, water softener, gas furnace, washer,
Basement
dryer
Kitchen
Refrigerator, stove
u
i
✓ �� _:�. i �* irk „��.} t , �} �` * w 4J •
7. Air Conditioner
9. Kitchen Refridgerator
11. Washer and Drier
8. Kitchen Stove
10. HoneyWell Thermostate
12. Fluorescent Light
13. Water Softner
15. Smoke Detectors
17. Capped Pipe near air conditioner? (possible oil
tank)
14. Uncapped Well
16. Hot Water Heater and Gas Furnace
18. Attick
19. Vermiculite in attick
20. Asbestos Floor tile in basement
22
Tar paper under cedar siding
20. Asbestos Floor Tile in Basement
21. Roof shingles and tar paper
23. Window Glazing
24. Window Glazing
26. Garage roofing and shingles
28. Cement Stucco siding on Garage
25. Sealant Caulk
27. Window Glazing
29. Plaster ceiling in garage
30. Asbestos Textured Ceiling in living room
34. Paper under hard wood flooring
31. Kitchen Linoleum
33. Sheet rock walls
35. View from front of house.
EMSL Lab Results
EIVISL Analytical, Inc.
14375 23rd Amnue North MInneapolis. KM 55W
Tot1Fa:: gW) 4494922 ) (M) 44964924
http:j' www.EMSL,0on 1 mmtl�pWglgprl�emsl.Com
Attention: Douglas E. Hickey
Hickey Consultants
4301 Spruce Way
Maple Plain. MN 55359
SW032817
EMSL Order. 351701995
Customer ID: HICK55
Customer PO:
Project ID:
Phone:
(763) 479-3214
Fax:
(763) 479.3214
Received Date:
03F2812017 4:20 PM
Analysis Date:
03*112017
Collected Date:
Test Report: Asbestos Analysis of Bulk Materials via EPA 6OLVR-93f116 Method using Polarized
Light Microscopy
NonAsbm
Asbestos
sample
Des -Won
Appearance
% Fibrous
% Non-FMmm
% Type
VM1-01
VERMICULITE ATTIC
BrvNFVTan1Cadd
3%Cellulose
95%Vemricufde
-1%Aclirmrrle
INSULATION
Non -Fibrous
2% Non -fibrous 40ther)
359700"s-Mr
HumogeneM4
VM1-02
VERMICULITE ATTIC
6roxr4TanlGot1
214Cel4dose
97%VermIcuQEe
0%Actirmgle
INSULATION
NVon-Fibrous
1%NW[ibrous[other)
1Sr7d$*§54=
Httrrrogeneores
Vm1-Q3
VERMICULITE ATTIC
Brawn TaalGold
10%Celgdase
90%Vrehrlicu to
Noft Detected
INSULATION
Fibrous
,MUQINS, r
Hamogenoars
Vmrr xAWr is a Wrorm prabt an ma4iv and a regv vv msdl camor be puvrarlaed- Addd'wve✓ mmVzrs is recamrmnded.
VM1-04
VERMICULITE ATTIC
Tan/Silver
15%Ce14Aose
65%NWs ibmaAlOther)
Mom Detected
INSULATION
Non -Fibrous
8S0701"5O01N
HOmogent
Vennauke a a Wtmn problem WAs" and a regmWe muV mma be pueramea Addbwm aeelPEis a reew"rmmfad.
VM1.05
VERMICULITE ATTIC
TaNSily r
5%Cellutse
96%Nor"brokls40ther)
<1%Actmorrm
IN$ULATltjfi
Non -Fibrous
36r70t"50=
Hwnoganra A
RM 1-06
ROOF OF HOUSE •
6rmr.Red/61ock
25%Cellulm
75% Non•fibmus (Other)
Norte Detected
SHINGLES
Fibrous
Yir7ar0aSGk7rd
Heterogeneous
TPI-07
TAR PAPER UNDER
Grade
50%calhAose
45% NonAbrous 40ther)
None Detected
HOUSE SHINGLES
Fibran
<11%G11233
ssr7aressmo:
Homogeneous
5%Hair
CM2-09
BLACK CAULK AT
slam
10%cantaose
90% Noo-fibrous (Other)
Mom Detected
BASE OF HOUSE
Nar�Fibrorm
77rrarRPSiGca
Hsnogenea4
CM3.10
WHITE WINDOW
Wrdls4leve
100%kbndbrous 40thm)
Norm Detected
GLAZING
NWrFibrous
3sr7areasmct9
Hontogens�e
CM4-n-Brown Layer
BROWN WINDOW
Brown
100% No"brous (Other)
Norm Detected
GLAZING
Non -Fibrous
X F70slO mfo
Homogeneous
CM4.11-White Layer
BROWN WINDOW
Wldle
100% Non -fibrous (Other)
Mane Detected
GLAZING
NmwFibmus
.1SM1995-m"
Hanogeneaaa
TP2-12
TAR PAPER UNDER
Black
40%Ce&Aose
5ft No"brous (Other)
Noire Detected
CEDAR SIDING
Fibrous
10%Hair
33"090050m
Homogeneaam
RM2-13
GARAGE ROOFING
RcdrBlack1Gmm
30%Ccllubse
70% Non fibrous (Other)
Norio Detected
SHINGLES
Fibrous
33r70rff5-Wr2
Nmerogenems
TP3-14
TAR PAPER UNDER
Black
50%Celhdose
50% No"brous (Other)
Norte Detected
GARAGE ROOFING
Fibrous
85070ros5cV0
mornog-
CM&IS
GARAGE WINDOW
Brm r►Wh4*
100% Non -fibrous (Other)
None DebKta-d
GLAZING
Haar -Fibrous
3SON0195mr4
HemogenecR4
t*W repotl from: 03011=7 15:25,24
ASB_PLM_0000-0001 - 1.78 Primed 3/3112017 2:25 PM Pape 1 at 2
EMSL Analytical, Inc. BOLOrder: 3517DI995
Custtorller 1D: HICK55
14M 23rd Avem s North Minneapdfa, Mn SOW
Customer PD:
TeVFax (783) 449-49221(ra3) 44&4224
M1p:ltwww.EMSL.oan 1 minneaporisWb@enhsl.com Project 10:
Test Report: Asbestos Analysis or Bulk Materials via EPA 600IR-931116 Medtad fusing Polarized
Light Microscopy
Sample
Description
Appearanee
% Fibrous
% Non-Fgwous
% Type
SM 1-1 B
GARAGE CEMENT
Gray
100% Non•farous (Other)
Nan* Detected
STUCCO WALL
Non-Rb aw
ash MIM data
Hamogeneoua
PC1-17
GARAGE (PLASTER
Grey
-C196 Cellulose
100% Non -faros (Other)
None Detected
CEILING
Fibrous
3D1fi*aae-0orr
Homogerieaw
FTi-18
KITCHEN + DINING
Brcr*nS8ig8
100% Nor0brous (Other)
Nana Detected
LINOLEUM
Non•Fibroas
3,h7p�sOe�hprT
FLOORING
Hornogen*ous
SM I-19
LIVING ROOM
Vfta Gdd
10% Mica
3% Chrysdile
SPRAYED ON
Faro -Fibrous
87% Non-Nwous (Other)
»rrarorsmae
CEILINGTExTURE
Nomogemous
SR1-20-Plester
SHEET ROCK WALL
GraVIBeige
5% Cellubse
95% Non -fibrous (Other)
None Detected
BOARD
Fit"
svmrlas mra
Meeerogenears
SRi-20-Skim Coat
SHEET ROCK WALL
While
100% Norrfbrous (other)
Now Detected
BOARD
Non-Fitir*A
35im ss-aw"
Homogeneww
FT2-21-Floor Tile
BASEMENT FLOOR
Tan
95% Non•fiuous (Other)
5% Ctaysclile
TILE R'x9'
Norte-Fibrorw
aseIVIMDean
0Im. ogeraous
FT2-21-Blaats Mastic
BASEMENT FLOOR
Black
100% Non-Rxouss (Other)
None DMoctod
TILE 9'xV
Nor- brows
3V'Mf e-KMU
Norry9w5mova
FT2-21-Tan Mastic
BASEMENT FLOOR
Tan
100% Non-NNOA (Other)
Nam Dolatod
TILE RpAr
Nonfibmua
35e ro+aa54MM
Flershogerhrepvs
FT3.22-Linolaum
SPECKLED
BrowtdYellow
80% Ce&AM
35% Non ferrous (Otlror)
None Detected
LINOLEUM
Ferrous
5% Hair
3511T aM-V a'r
FLOORING
"awopheoui
FT3-22-Mastic
SPECKLED
Brown
100% Non -fibrous (Goer)
Nona Detected
LINOLEUM
Nw-, Rbrous
asrgr.aa�.ptrrwr
FLOOMNG
HamOgenepus
TP443
RAPER UkDER
Tan
90%Cefluloee
10% Nan -fibrous (Other)
None Detected
FLOORING Fbrous
1SI W204X12 Homogerleoue
AnSt"I(S)
George SufS— (25)
Sfoplrardo Cowbmy f2)
RedrelTrmia. Laboratory (Nana
or Other Approval Signatory
EMSL ohaduffns kawt, li, to ooa of aulyea.. This ,ease rase ontr to ft sm. as reaorsee " may rot the repredroed, empt In tub, w t ha.1 widova en apprl by EMSL. EMSL boom me
Mwans*1*1 for sarrpls cNIcclYfh 9COVheCs 9r analytical rthe;drptl 1...4kJM 3s 1ntp�Oon an0 wear DC9t results irc Nre R a+hsOeb 01 aT Wert This rqW mkt nct Oe wC0 try Ng dCnt to dawn
product ow0crogn. approval. or wxWsement try NVLAP. NIST a ony apancy of the Wwal gwommeat NprFfrgOes orgarKany lharehp mararlala pr*wM a prQ*Qm matiu arid thiastm EMSL
r cwmnwno gmvsnaerk r oxOon prior tD ar*p*W Samples raeaivad n good ow4ftn heroic Wgnmov reetpd Units
MWWOed by the dlern. h*Wo ffwWnefs mamAam,red..an Munole twers (i.e- Wboift m. w*stoma ett) ere retorted es a tope sampe. Repo" Will re 1%
6wrobs armymd by EMSL ArrelygcK ft. Mrr maths. FAn NVLAP Lab Oode 2CM9-0
frtbal report from: 0313112017 1525:24
AS8_PLN-Odo6_0001 - 1.78 Primed: 313112017 2:25 PM Page 2 ar2
OrgerlD: 351701995 Asbestos Chain of Custody
EMSI ANALrrcaL, Inc
EMSL Order Number cab um 14375 24V E VE NaK-N
MINNEAPOLIS. UN55447
a�►�utin...• oc
PHONE: (763; 449.49n
....�.�...�,.,,..� FAx (7653; 449-4924
Com : Hick Consultants
EMBL$in to: Same Ddkmd
Ir M to Is Ddkmd Lift In Cor dmW
Wore WRt" ardhonzah w tram INW party
Br.eeb 4301 Spruce Way
CV. Maple Plain
Pta"rt To ante : DoWlas. E. Hickey
StatalProAnoo: MN
Zlpfpostal Cods: 66359 WCovlr. .. USA
Fax 9: 70 479-3214
Telephone V. 753-479.3214
Pra ect NanralNurnber. SWO32817
_
Email Address: dhick4 mmmQyM"., omry__.,
Please Provide Results: Feu
EmaT1 Purchase Char- U.S. State Semplas Taken: MN
- Tumaround Tian A onW - Please Check _
3 Now 8 Hour 24 Hour I Ij 49 Hour I Rg 72 Hour I98 Hour 2 week
For TEMAv 3 hr N cup B hr. p"" wB ehaW to SftM ra.'Mam a a pmffa n dwptw 3 Mw TWAHERA orbPA L@ M A TAT. You wrY v asked b sVm
an a 0mz3 rn Ibm Rxlha wA*ce Aharyw n ae+2orntM WO EMSL's T&M end loeaM ih Me Phc* Gm4e.
ACM - Al r
El NIOSH moo
[) „d OSHA Shr. TWA
Yam- Ir ❑ 4461u TAT "Emonsy)
❑ AHERA 40 CFR, Pad 763
❑ NIOSH 7402
❑ EPA Level II
❑ ISO 10312 - -
TEAR. Dust
❑ Mkaovac - ASTM D 5755
❑ Wipe - ASTM D6480
❑ Carpet Sanitation (EPA (i00UJ-931167)
SoKftckJ%Wm9cuhV
❑ PLM CARS 435 - A (0.25% sensitivity)
❑ PLM CARS 435 - 9 (0.19h sensitivity)
❑ TEM CARS 435 - B (0.19i sensltivrty)
❑ TEM CARS 435 - C (0.01 % sensNlvlry)
❑ EPA Protocol (Seml-Gusi tetive)
❑ EPA Protocol (Guwfitathe)
FLM - Bnl f[epoitlnu Ilrnitl
PLM EPA 600fR-93f116 (<1%)
�] PLM EPA NOS (<1%)
Fbird Count
0 400 (<0.25%) 0 1000 (<0.1%)
Point Count WGravimetric
[] 400 (, 0* 25%) ❑ 1000 (-cO.1 %)
❑ NYS 198.1 {triable in NY)
NYS 198.6 NOB (non-MaW"Y)
NIOSH 9000 0%
W-
.TEM • Bulk
[] TEM EPA NOS
❑ NYS NOB 198.4 (non- dvb1e-NY)
❑ Chatfield SOP
a TEM Mass Analyds-EPA 600 sec. 2.5
TEM-ilVatar EPA 100.2
Fibers }10pm ❑ WaM ❑ Drinking
AIt Fiber Sass L] Waste ❑ Drinldng
Other: —�
® Check For Positive Stop - featly lden!'j Homogenous Group
Samplers Name: Douglas Hk;key
Samplers Signature:
SeanPle /
Sample kut
VolunWAme (Air)
HA 0 ufk
DataMnw
id k
Adijed
r
L '6it,4j!stjbWjfAJ
//
... S e
r
Jpr'
s9•E
64 we
plant Sample a ge :
Total A of Barn lee:
ftll"utslted (Ctlenl) cj
Def. Qj % Tirm:
lioceived (Lab): 4
Dom: ��slr7 Time: lJ
CormrerrCw3wiallnslnr s:
an-ONwamm-w..wcoc-w. „nome Page 1 of pages
Paqe 1 Of
I
r
nas arrenaea ana suvmquuy cumpicum an
AS INSPECTOR
ZEF"SHER TRAMING COURSE
permitted by
clf'hlinmesota under Mbmesota Rules 4620.370Z to 462.0.3722
mid meets the rents of .
r 206 of Title it of the Toxic Substances Control Act (TSCA)
conducted by
e Startes Env ronmenta4 Ltd.
&BIPMOR
0000
millgWon
„
s—L"t
-—_� —
MA
Tils is.tv' c,edffy. that
Heidi BUX
,has attended ands uccesyfully completiqd ah.
ASBESTOS INSPECTOR
REFRESMER TRAINING COURSE
permitted by
under.-Winnesota Rules 4620.-3702,to,461, 6`3JJ-2
Mid meery the requirements Of
Section 206 of fle 11 of the ToxicSuhstances Control Act '�(T. ScAj'
cunducte'd h.v
Lakearaves Environmental,. Lid,"
in
White Bear Lake, MN on September, 15, 20101.,
Examination Date: September '15.,201-6-
M
4"
Map Basement of 2496 Black Lake Road Asbesot Survey. Yellow=Asbesots Containing
W ��
fr
SO�V►�
1"
QQ '
r.
_
t i
i
LA
r
7
I
n-
'
y,
;
i
rV
r:
r
License lookup
Page 1 of 1
MINNfi80TA DfiPAI:IMfiNT OF
LABOR &INDUSTRY
License/Certificate/Registration
Detail
Class Type:
RESIDENTIAL BLDG CONTRACTOR
Number: BC594315
Application No:
230184
Status: ISSUED
Expire Date:
3131/2018
Effect Date:4/1/2016
Ong Date:
10/10/2006
Print Date: 4/11/2016
Enforcement Action: NO
Name:
STONEWOOD LLC
Address:
153 LAKE ST E
WAYZATA , MN 55391
Phone:
612-462-4000 Fax:952-697-5591
Other:612-267-2670
Business Relationship Requirements
Name:
GUSTAFSON, JEFFREY S LictReg No:
OB143690
Status:
ISSUED Application
No: 269360
Expire Date:
313112018 Effect Date:
4/1/2016
Orig Date:
5/20/2010
Another Lookup?
https:Hsecure.doli.state.mn.us/lookup/licensing.aspx
5/16/2017