P - 40013C�TY OF FRIDLEY MOVING [] DEMO (j�] PERMIT APPLICATION
, ��31 University Ave NE
'Fridley MN 55432
(763)572-3604 FAX (763)571-1287
Job Address:
Legal Description:
Owner & Address: (
Contractor:
Address: Jr' %
State License #
DESCRIPTION OF BUII,DING
HOUSE: Length Width Height Sq. Ft.
GARAGE:Length Width Height Sq. Ft.
OTHER: Length Width Height Sq. Ft.
Estimated Cost $,Z,pbb �(� Approx. Completion Date
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CALL GOPHER STATE ONE AT 651-454-0002 FOR IITILITY LOCATIONS. CAI�L AT•T•
UTILITIES FOR DISCONNECTS BEFORE WRECRING MOVING STRIICTURL.
Moving Route:
APPROVAL(S) REQUIRED PRIOR TO ISSIIANCE: SCANNED
l�CA: NOTIFICATION OF INTENT TO PERFORM A DEMOLITION (� YES () NO
T�AT�R AND S�WER DISCO�CT PII2MITS MUST 8E ISSDE� PRIQ�t '�1D Lffil��LITI0111.
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D�.�.@Ct
naitions
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�ditions
Conditions
] Signat�s�re
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The undersigned hereby malces application for a permit to wreck/move the b�ilding described above, agreeing W do all work in strict
accorda�ce with tl� City Ordinances and nilings of the Building Division> and the State Code which requires any water well an the
property to be sealed by a State licensed water well driller, anci hereby declares that all facts and representations stated in this application
are true and correct.
ALL DEMOLTTON DEBRIS, INCLUDING �'OUNllATION & SLAB, SHAI.L BE REMOVED FROM S1TE.
D N D l- /l �-��;,,�`"G C�.�
Date Si�nature
Movin
Principle building into Fridley . . . . $300.00
Accessory building into Fridley ... $ 42.00
Through or within the City ......$ 20.00
Move a building out of City ......$ 20.00
Wrecl�n
For each 1,000 cubic feet or fraction:. ....$1.25
For st;rructures which would be impractical to
cube, the fee shall be based on the total cost
of wrecking at the rate of $6.00 for each $500.00
or fraction.
PE��J�: � P R O 1 Z O ��INIlVIUM $20.00 Oifice Use Oniy:
Effective Ol/01/2011 l� j� � � (�
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SAC-D form comple.ted
' ' ` t��nne�+�ta �'ai��tio�
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��o L,��y�t�e �a�� �v����t�
s�. ���,�, r�� s��ss-•a���
N��if�cat�c�n of Intent to
Perform a [�emc�litior�
Asbe�tvs Program
Doc Ty�re: N4fificafion
Type c�f nc�tifica#ia�n� � Qriginai ❑ Amended ❑ Projecfi car�cellation
Nati�catior� must be pashnariced or received ten (4Oj worising tfays ts�#ore demcslitian begins. See item 5 for emergency
demolitions. Bvth start and end da#es shouid b� ame�d�d in writing as necessary to reflect current praject dates.
Demoiitaon Cantractor
Name: Buber Recyciing & Compos#rn�lnc _J_ _
Add�ess: 5754 Memoriai Ave N
City, St�te, Z�p; _:St�llwater, MN 55082-1088
Phone r�umber: 651-439-8399
Gontact name: I�b Buberl
Phnne number. 651 439-8399
Buildi�� t'nformati�n
Suilding name:
Address/Location. 434 Liberty Rvenue
Ciiy. Sfa#e, Zip: _ Fridle�r NIN _.
Caunty . Anoka _____..___:----
Piione number:
Age of blct9 4Yrsj: ------ Size 0# bldg {sq ik): 1,364
Num6er of floors, including basemeni [evsl(s}; �1
Building t}wner P�es�r�iuse�f��a�; .. va�r,x_ .._�.�.. „ �.��m �._��..._:.
Name: `Gity af F�idle.y _ HRA --_. __.�....._._ Prior use of bldg: : resider�aal
Address: 6431>un�versi Ave NE
_....�.�!_...._ _._„�_.
Cit , Sta#e, Zt : Fr�dley,_MN 55a32 Dates c�f d�mafit[an ar intentiona! burningc
Y p . .._------ -- __._,...
F'hone number: 783-571-3450 Start date: Q4111/11 End date: U6��I11
_... ____ __�__..__.__.�.___,.�.�__ _.._— ._.....:,
_. �_.,._..____ w._.._...,._—
Contact name: La ne Otteson 'n"y� ��'
_�.`.. _ . . ...... ... .. __— __...�.�..._..
Phone nwmber: '7$3=238-8048
No#e: If there is �260 linear feet ar >160 square feet of Regu#ated Asbestos.�Contain9ng Material (RACM); in the hu'rlding ta be
d�malishsd, it must be removed by a licensed asbestas a7ntractot `prior to demolition. The S#at� of MN-Notice of lnte►tt to
Perform an Asbestas Abatement ProjecC http:/lwww.pca.s�ate,rnr�,saslp�blicatior�slw-sw4-t�.dc�c must be used ta notify for
the asbestas rema�aL
ls nonfriable A�M pre�en# in the structure to be demoiished? ❑ Yes � No
�It non€r�able ACM be present in the structure at #he time af demalitian? [] Yes � No
If Yes to both qu�:stia�ns above, camplete I#ems 1-9. If No #o eithe� question, eomple#e lterris 3-9.
1. ff ACM wilM lae I�ffi in plaee far the demoliti�an indicate �e amaunt af Gategory 1 andtar Gabegory 1� narFfriabfe ACM left
in piace.
Ga��gory l: __ .�_. ..._.__ __._ Linear feet Categorylt` Line�rfe�t
Sguare feet �� Square feef
__..._ � . �.___,� � ..
.�:.. _...___._._ Cubic feei Cub[C feet
Cat+�gory I nor��Sab1s ACM rneans asbesfos-cdntaining Cat,�orY 11 nonfriable ACM_means any materiai. exduding
padcings, gaskeis, resi{ient flaor covering, and asphalf Categary ! nonfiable RGM, ctmtaining more than or�
roofing products containing mare than one percer+t �rcenf Asbestcts that, when ctry; eannat b� cxumbfed,
asbestas, pulveerized. cyr redut�d tc� a R�der by hand pressur�e.
�ategory I nonfriabte ACM is not afiowed to remain Categary !i nantriabte AGM Ps nc�t atiowed ta resnaf� in
in. place f�r d�m�li�ion if it is in poor condition, place fo� demoii#ion i# it':fiars a high pr+ababiiity of becoming
crumbled, pufverizetl, ar reduced to a pdwder d�ri�rg
demWitior►. trar�pc�t, or #ispr�sa9 {e.g., transite�>c�ement,
sla#e roofing}.
w�vw.pca;state:mn.us • 651-296-63Q0 • 800-b57-3864
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• Til' 651•282-5332 c�t' $Oti-:657-3864 ,
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,,�. L�escription and Pcscatiarr of ACM reenaining irr place (inciuding number af floors and raomsj:
3. Company andfor �ndividua! that conducted the buildirtg inspe�tion a�d the peocedure used tc► determine the presenc�
or abse�ce nf ACM {including anafytic methad}: (Note: Prior ta demolition all struetures must he inspecfed by a licer�sed
asbestos inspector wha has been certi�ed thmugh #he Minnesota DepartmenC of Heatth:)
�i�sch Associates, Inc Mike Wiliey _ __
4. Description af ptanned demolition and thQ specific metMad(s) thatwili be used.
baekhoe
5. !f ths demoliiion was ordered by a government agency, please identifiy the agency and attach a copy o# the order:
Name: Layne OtteSOn _..� _ Title: Asst Public WorkS Direetor .. _:__._
Autharity: _ Ci„ tY of Fridiey -„HRA �� ._�._
Date of order (mmfdd/YY3� .._03/02111 ..�_._..,.._..... _ . ....<.. Start date (mmid�lyy): U4111/'f1_ ._ ___
lVot�fication for an emergency demafitian must t�e submrtted as early as possrbte bet'or� derno�iNo» begins, but nat t�rterthan
the fiailowing woriciRg day. A demalition is consider�d ar► emergency anly wher� the fac�lity has been deemed structuratiy
urtsound and an danger of imrninQntcoNapse. If the struclurally unsound buikling is known to confain any regula#ed ACM oris
scaspected to carrtain any reguiafed ACM, special procedur�s mus# be foEJowed 1f you ar+e unaware;of the speCia! pr�tcEtlures,
instnrcfions/regufatioras ear� be obfained by contacting ihe Mi»nesofa Pottufion Gontro�Agency (I�tPGAj af the atfcfress vt
phone numberlisted below.
6. qescriptian of �Srocedure to be foilowed in the event that unexpected frAGRlI is fa�und or Categary fl nonfttabie AGM
becames crum6l$d, pulverized or reduced to pawder.
Contact Mike Witley af Liesch Associates
7: Demolitio» waste transparter(sj information: 8. Demolitivn �raste disspasa� in%msation:
Transporter name H& T Truckmg Inc._.____ ._._. Landfill r�ame: Vortco ll
Cantact name: Rob Buberi Own�r/Qperator. --V�it Com�anies �
Tranpart�raddreSS �750 Memorial Ave N Addresstt.oration: 1500140'n Ave '
._ _�.�.._ _.� �.
Ciry, 5tate, Zip: __Si�ilvuater, MN __55082 __ Cify, State, Zip: Becker T��MN 55308
Phone numher. f51-439-OQ22 Phnne.number�` 763-262-8662
9. C c�rt�fy that ttte above infonnation is carrect and t am a l�naftde represen#�tive af the demoli#on cc�ntractrsr drr
building owrler �nc! have authority to enter inta agreements far my employer.
Print name: _ Rabert Buberl T�le> Pres
� _.�.._ ���i / .. ..�_.__ _..v ._...�:.. �._.�_�.,. .. � ,..._ .� _:. .__ . ...:.. _..�.
�ignature: "� ---� �1��''� � Date;03i�411�9 � � � �
11ttpOrtant Not�.
Ensure you are Rn campiiance with Minr►. R. 7Q35:t�80� priar to the cammencemenf of renovati+ontd�noiitie►n.
This ruie requires thaf the foklawing i�ems be removed two days prior to demtrGtian: mixed muniapal solid:waste; household
hazardaus waste; industriai ar hazar�ous waste; waste tites; major appiiances; items cantainin� eiernental mercury, Poly-
Chlarinated SiPfienyls (PGBs), and chlorofluorocarbons (GFCs); oil; tead; eiectror►ics; and o#her prohibited items. See MPCA Web
si#e at r���avv.�ic:�.st�t�.mn.u�'p��t�lic��Yic�rfislw-gu�#-2�?.�ad�' for a Pre-Renovation/Demoiitic�n Envir�nmenta! Checklist Guidance
Documantto assxst with completion of this rule.
Submit to: Minnesata Pollution Control Agency Questians +eall. 65i-296' 6300 oc 1-800-657-3864
Industrial Division — Asbestos Program
520 Lafayette Road North
St. F'aui, MN 55155-4194
E-rnait: asbe�4o�.:d�t�t�iitacmn.pc��sfiafi�.mrt.t�s
Fax: &51-2�7-l438
_____. _,._.�___ � _..... ... _..�_.._ .__�.�... ._.. . _.�---
www.pca.state.mn:us b51-296-6300 • 800-657-3864 • TTY 651-282-5332 pr SK�-657-3844 Available 1n altemativ�e formats
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