Permits - Permit# 10-02DEM - 4341 Channel Road - 1/1/2010 (3)Date Received
at City hall: Permit #: D- OD- OE i
Application For Demolition Permit
City of Spring Park, Minnesota
Fee: $40
Name: O G��.,� D ('Cc�J (C— �, TQ- C 0 Telephone No.: _
Address:
Demolition Property Address:
Type Of Structure: _ c..� C- t-
Approx Date To Begin: S` [ O _ Estimated Completion Date: �c� (v /A ( - 2-3 1
Utilities On Site: Check (✓) all that apply Sewer ✓_ Water Electric J v
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..
\\gill Utilities Be Used For New Structure'? .................. Yes V 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 Pub c Works Department.
Is There a Water Well On Site? .................................... Yes No
Is There An Underground Fuel Tank? .......................... Yes No (/
Demolition Contractor: O al Telephone No.
Address: / / '-(C) ( o Q �- /� 1, -k/S ,
Liability Insurance Co.
Policy No:
Policy Period From: To:
Telephone No.
Coverage And Limits:
Note: In the event that and ASBESTOS is present in the structure, state approved methods must be followed.
1 hereby declare that 1 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 the permit is a trKand correct statement of my intentions.
Signed By Applicant:
Permit Approved By:
Title:
Date: (� 1/0
The Following Section To Be Completed By Cite Officials
Total Fee:
Receipt No:
Date: Received by:
The Following Section To Be Completed By Public Works / Operator
Water Service............ Disconnected Abandoned Scaled Signed _
Sewer Service............ Disconnected
Electrical Service ...... Disconnected
Gas Service ............... Disconnected
Abandoned Scaled Signed
Abandoned Removed
Ahandoned Removed
_ Signed ___
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:
l . 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 this application are complete, true and correct.
Applicant's Signature
Owner's Signature
Approved By:
Page 2 of
JUL-OB-2010 08:31 BOLLIG AND SONS INC 9529389615 P.02
I U111 . 1.1 I 1 U1 1;1 111 %U 1 R.", v - --
CHECKLIST FOR DEMOLITION PERMIT
Project Name: Kt,-s K n _ Cate 7—
Address: �"r'� �I.t�.l�,e�J _ li4� City: S,0 f "."
Owner's Name: _r bo K.-.S �,q wo- Telephone Number:
Contractor's Name: 12C301se
tsok)-i Telephone Number: �tSZ- ?3p"`�(��
61/
Detailed explanation of work to be perfo ed
c, ,1 o -C /
Has the following been provided or completed
Yes No NIA
❑ &� ❑ Completed permit application submitted to the Municipality.
[] 0' ❑ 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.
❑ ❑ Written verification and/or site plan identifying the type of pedestrian S � (f-
protection being provided. Describe type, location and height of t4 r' ,
fencing to be used.
❑
❑
Have all utilities been properly terminated.
❑
❑
Has a "Notification of Intent to Perform a Demolition" (not required for
single family dwellings) been submitted to the Minnesota Pollution
❑
Control Agency. /I
Have all wells been properly abandoned in accordance with State
/
Health Department regulations.
❑
❑
Septic tanks pumped and removed.
❑
❑
❑
Written description of building demolition method provided.
L] [ J QjJ Are there any underground storage tanks to be removed.
❑ ❑ Performance bond, letter of credit, escrow or securities provided
in accordance with the Municipality policy.
❑ ❑ Have all hazardous materials been removed and disposed of in
ordance with the Minnesota Pollution Control Agency.
Signed'
c>-�c�' Date: 7— -
September , 2007 Demolition
Page 2 of 2
JUL—OH-2010 08:32 BOLLIG AND SONS INC 9529399615 P.03
rOr6.ul i 1 ur Irnl YU rnnn--
Permit Submittal Checklist: Demolition Permits
Permits are required for all building structures and/or interior building demolition work. The permit fee
is based on valuation and must be submitted to the building inspection department for review.
If a new structure will be built immediately following the demolition of the old structure, and
they are applying for the permits at the same time, then two permits are issued but the
valuation of the demolition work should be included in the valuation of the new permit.
If a new structure will be built sometime in the future, and is not applied for at the same time,
then two permits will eventually be issued. Therefore the permits will be issued separately,
one for the demolition and then one for the new construction permit, after they are reviewed.
It is the responsibility of the owner and/or contractor to comply with the requirements and rules of all
authorities and government agencies having jurisdiction. The permittee shall be responsible for
contacting all of the proper State, County and Local authorities prior to the demolition commencing.
All asbestos and other prohibited materials shall be removed and disposed of in accordance with the
rules and regulations established by the Minnesota Pollution Control Agency. The Department of
Natural Resources, County Environmental Services Department, County Watershed, City Utilities and
Public Works Directors are examples of agencies and/or authorities that may be involved in any given
project and a demolition permit issued by the Building Inspections Department shall not be construed
as permission to proceed without approval from all appropriate agencies.
Submittal Requirements:
❑ ; Application
[Q' Checklist for Demolition Permit with appropriate requested information attached
Required Inspections:
❑ Prior to demolition the following items must be checked and remain in place throughout the
duration of the project:
❑ Traffic control
❑ Pedestrian protection
(Silt fence — dust control
❑ Owner/contractor must provide verification of proper clean-up and disposal of
contaminated soils, and all abatement issues, and disconnects
(see permit packet for requested documents)
❑ After the demolition project has taken place the following items must be checked during the
final inspection:
❑ site properly cleaned up and appropriately graded
❑ Street cleaning
If you have any questions regarding the classification, removal, transport, disposal, or any questions
regarding asbestos rules, regulations, or standards, please feel free to contact the MPCA asbestos
team at the following numbers:
(651) 296-6300
(800) 657-3864
Information is also available at the MPCA website: http://www.oca,state.mn.us
5epte nber 14, 2007 Demolition Page I of 2
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