Permits - Permit# 3-24-17 - 2494 Black Lake Road - 1/1/2017 (5)Date Received
at City Hall: Application For Demolition Permit Permit #:
City of Spring Park, Minnesota
Fee: Based on Valuation and Requires a Building Permit
Name: S,-a Nr L-) oopC Telephone No.: 6, l Z-- 4.6 Z-}600
Address: l 3 L R-,Lt '�T - �:, by 4----L &yyY . t^ /,,j
Demolition Property Address: G ` °` q' f�L Ar-K-- L A,,
Type Of Structure: j 1r F+ rr.
Approx Date To Begin: q .11. 1 -+ Estimated Completion Date:
Utilities On Site: Check (✓) all that apply 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 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? .................................... Yes No
Is There An Underground Fuel Tank? .......................... Yes No
Demolition Contractor: I1r Telephone No.
Address: 2"i 1 %� r ►.,r� �-y� a t<, ar �C`[ t • ��i •y [ S M o.1 �'
Liability Insurance Co. u Gtc r v'e- CG-S C ka ,,, Telephone No. ,-,,—� 76Z-6r73-�DoO
� CCw,`�5 �6 � S-4- > j:�S
Policy No: fvG J`� �l �f � 3 Policy Period From: !/ 1- It To: _ «!/
7l/ 7- Coverage And Limits: 4T kr"
Note: In the event that any ASBESTOS is present in the structure, state approved methods must be followed.
I hereby declare that I am the owner of the property or the demolition contractor of above described property. I agree to comply with
all state regulations and all materials from the demolition will be taken to a state approved demolition dumpsite. All the foregoing
information contained on this permit
t is a true andcorrectstatement of my intentions.
mi
Signed By Applicant: l I I! ✓j1 Date:
Permit Approved By:
Title:
Date:
The Following Section To Be Completed By City Officials
Total
Receipt No:
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
Removed
Signed
Gas Service ...............Disconnected
Abandoned
Removed
Signed
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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 made on s application are m lete, true and correct.
Applicant's Signature -�
Owner's Signature
Approved By:
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