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P - 41806JUL��,S/20i�1.�l�ION 08:27 AM LYON CONTAA�TING . FAX No,320-252-3603 P, 002 ` CITY OF FRIDLEY MOVING [] DEMO [��-PERMIT APPI,YCA ION 6431 Universi�Cy Ave NE ( a� ��� �,.J!'�l Fridley MN 55432 (763) 572-3604 FAX (763) 571-1267 REC'D AUG � g 2011 Job Address :/�B� /Yl�sr�sc� P�� ST,��� ��_c_yrQQJ_V SS�f,,�� Legal Description: j,��.�/s,�-��Y�f-3F6�r�L�T'� un�n��s�e�d�► Owner & Address :��NEIA.•�lN�,d�q�k��,v f,Ne,,i � . ,�s�i,_�—� Contractor : Z��-EL CUNT2AC.T t r�br Address: ���� )�.p���' ��,Mi�.,���. ,�,�N State Lxcense # _ DESCR�TION OF BU7Ll�i�li 'G rutc�cl . �B_ �NOIu,C� Te1, . #�tS2 • 4ras��groo Tel . #��°3�4?`� b5� HOUSE: Length �. � Width 3Z•`�' Height 25 Sq, Ft. j,t70S Cu. GARAGE:Length Z4,3' Width l�•� Height q Sq, Ft. 3"7� Cu. H R• L th 6�i'd ' h Ft . �s, � a�s' Ft . '3�,3�� OT E. eng 1'th Heig t Sq. Ft. Cu. F'C, � Estimated Cost $ Approx. Completion Date STATE ONE AT 651-454-0002 FOR UTILITY LOCATIONS, S FOR DISCONNECTS Mo�ring Rou�e : APPROVAL(S) REQUIRED PRIOR TO ISSVANCE: MPCA: �10TIFICP,TION OF INTENT TO PERFORM A DEMOI�ITTON (�YES ( j NO WATER AND SEWER DISCONNECT PERMiTS MUST BE ISSVED PRIOR TO .LITION. �Water�l Pa.i�r. Ye� or Collect [$ � Signatur � ❑■ O Engineering ons Conditions O Fire MarshaY Condita.ons The undersigned hereby makes applicauon for a peaniz m wreck/�.ove the building described above, agreeing to do aU. work in saic� accordanec wirh the Ciry Ordinances a�,d n►liags of the Building Divisioa, and the State Code which requires az�y water well on t6c properry to be sealed by a Stare licensed water well dr3ller, aad hereby deelares d�at all f�acts aad represcatarions srared in this applieation are aue and correct. � a3 � Date Mo�ain� Principle building into Fridley . . . . $300.00 Accessory building into Fridley ... $ 42.00 Through or �vithin the City . . . . . . $ 20.00 Move a building out of Cicy ......$ 20.00 PERMYT FEE:��� � Effective 01/O1/2011 FROM Wrec � . For each 1,000 cubie feet or fraction.. ....$1.25 For structures which would be impractical co cube, the fee shall be based on the total cost of wrec�.n.g at the rate of $6.00 for each $500.00 or fraction. Mi1V't1�,U'M $20.00 Oi'%ce Use Onlp: SAC-D form completed ,� 2�i201 �/.1�O�i 08. 27 AM LYON �ONTAA�TING , � CITY OF FRIDLEY 6431 University Ave NE Fridley MN 55432 (763)572-3604 FAX (763)571-1287 FAX No,320-�52-3603 0 P, 002 MOVING [ ] nEMO [,�� PERMIT APPLICATION l REC'Q �UG 0 9 201� Job Address :/�g� /1'l� ct►cc. P�� .5 i- �Q� ni c,� /J�l jV SSY��.z�_ Legal Description: �,��Na������ 3F��.r�L_�T�7 �uvfraQ�s e�td,v�s,n� r �'e.� . Owner & Address :�a���i, r 1.%�q�,��e�r1 iriu,l.�lt�� ��(�i__c� � Contxactor :?��-EL C�NTQ�!{.T 1 n96r Tel . Address: LF17�c �1a.t)►i_o C� �T_AdItJ��l4t�cL nwni State License # - - —� DESCR�1'ION OF BUII.DI�i iG HOUSE: Length �Q.+-� width 3Z•`i� H�ight 25 Sq, Ft. j,t7aS Cu. GARAG�:Length Z4.3� Width 1�.'� Height � Sq, Ft. 3�a Cu. . OTHER: Length Width Height Sq. Ft. Cu. Estimated Cost � ApproX. Completion Date � •� NOt<� ,Ca #�S2 • �AS4�yr00 #�� 3• 2L . t Sb� Ft . �5, 1 �S� Ft . 33�rb Et. CALL GOP�R STATE ONE AT DISCONNECTS 87 651-454-0002 F'OR UTILITY ORE WRECKING MOVING STRUC7 LOCATIONS, GALL ALI� e Moving Rou�e: APPROVAL(S) REQUIRED PRZOR TO ISSUANCE: MPCA: NOTIFTCATION OF INTENT TO PERE'ORM A Di:MOI+ITTON �B'( YES () NO WATER AND SEWER DISCONN�CT PERMITS MUST BE ISSVED PRIOR TO �ZITION. ❑■ � ❑■ ollect[$ ]Signature ons tions O Fire Marshal Conditions � , . ► ,. _ � The undersigned hereby maKes applicaaon for a pcm�ic m wreck/m.ove rhe building described above, agreeing to do all work in s�ria a�cordanec wixh the Ciry Ordinances and n�liags of the Builcling Division, and the Stace Code which r�equires any wa�er well on sh� property to be seaied by a Scare licensed water well dr�l.er, and hereby deelazes �hac all f�cts and represeuracions sra�ed in this applieaaon are aue and correct. �L D�10LITON DEBRIS, iNCLUDIlVG FOUI�TDATION & SLAB, SHALL BE REMO'V�D �RO�1 STI'�. Date Si�n�a.ture Mo�air,� Principle building i,nto Fridley . . . . $304.00 Accessory building into Fridley ... $ 42.00 7'hrough or wittvn the City ......$ 2D.00 Move a building out of Ciry ......$ 20.00 Wrec . For each 1,000 cubic feet or fraction.. ..,.$1.25 For suucrures wl�ich would be impractical co cube, the fee shall be based. on the total cost of urrecking at the rate of $6.00 for each $500.00 or fraction. � pERMYT FEE; MIN�UM $20.00 Office Use Or�ty: SAC-D form completed Effeetive 01I01/2011 ` ` Minnesota Pollution Control Agenty 520 Lafayette Road Morth St. Paul, MN 55155-4194 0 Notification Perform a of I ntent to Demolition Asbestos Program Doc Type: Noti�cation Type of notification: � Original ❑ Amended ❑ Project cancellation Notification must be postmarked or received ten (10) working days before demolition begins. See Item 5 for emergency demolitions. Both start and end dates should be amended in writing as necessary to reflect current project dates. Demolition Contractor Building Information Name: Rachel Contrating LLC Building name: Residential Home & Detached Garage Address: 4125 Napier Court NE __ __ Address/Location: 1282 Mississippi Street City, State, Zip: Phone number: Contact name: Phone number: St. Michael, MN 55376 763.424.1500 Nick Bartemio 763.424.1500 Building Owner Name: Lakeland Construction Finance Address: 860 Blue Gentian Road. Suite 135 City, State, Zip: Egan, MN, 55121-1564 Phone number: (651) 994-4606 Contact name: Scott Thorson Phone number: (651) 994-4606 City, State, Zip: Fridley, MN, 55432 County: Anoka Phone number: N/A Age of bldg (yrs): 30+ Size of bldg (sq ft): 3015 / 372 Number of floors, inGuding basement level(s): 3/ 1 Present use of bldg: Residential / Garage Prior use of bldg: Residentail / Garage Dates of demolition or intentional burning: Start date: 8- 22 - 11 End date: 9- 30 -11 mm/dd/yy mm/dd/yy Note: If there is >260 linear feet or >160 square feet of Regulated Asbestos-Containing Material (RACM) in the building to be demolished, it must be removed by a licensed asbestos contractor prior to demolition. The State of MN-Notice of Intent to Perform an Asbestos Abatement Project http://www.pca.state.mn.us/publications/w-sw4-06.doc must be used to notify for the asbestos removaL Is nonfriable ACM present in the structure to be demolished? � Yes ❑ No Will nonfriable ACM be present in the structure at the time of demolition? � Yes ❑ No If Yes to both questions above, complete Items 1-9. If No to either question, complete Items 3-9. 1. If ACM will be left in place for the demolition indicate the amount of Category I and/or Category II nonfriable ACM left in place. Category I: Linear feet 500 Square feet Cubic feet Category I nonfriable ACM means asbestos-containing packings, gaskets, resilient floor covering, and asphalt roofing products containing more than o�e percent asbestos. Category I nonfriable ACM is n�t allowed to remain in place for demolition if it is in poor condition. www.pca.state.mn.us • 651-296-6300 • 800-657-3864 w-sw4-11 • 7/16/09 Category II: Linear feet Square feet Cubic feet Category II nonfriable ACM means any material, exGuding Category I nonfiable ACM, containing more than one percent Asbestos that, when dry, cannot be crumbled, pulverized, or reduced to a powder by hand pressure. Category II �onfriable ACM is not allowed to remain in place for demolition if it has a high probability of becoming crumbled, pulverized, or reduced to a powder during demolition, transport, or disposal (e.g., transite, cement, slate roofing). • TTY 651-282-5332 or 800-657-3864 • Available in altemative formats Pogetof2 ��. Description and location of ACM remaining in place (including number of floors and rooms�: Floor Tlle Tan located in the Basement - 500 SF 3. Company and/or individual that conducted the building inspection and the procedure used to determine the presence or absence of ACM (including analytic method): (Note: Prior to demolition all structures must be inspected by a licensed asbestos inspector who has been certified through the Minnesota Department of Health.) 4. Description of planned demolition and the specific method(s) that will be used: Total building demoliton utilizing an hydraulic excavator with various demoliton attachments will be used to demolish the buidling and load the material into trucks for disposal. 5. If the demolition was order9ed by a government agency, please identify the agency and attach a copy of the order: Name: Authority: Date of order (mm/dd/yy): Title: Start date (mm/dd/yy): Notification for an eme►g�ency demolifion must be submitted as early as possib/e befo� demolition begins, but not /ater than the following working day. A demolition is conside�ed an eme►gency on/y when the facility has been deemed structurally unsound and in danger of imminent collapse. If the structurally unsound building is known to contain any regulated ACM or is suspected to contain any regulated ACM, special procedu►es must be followed. If you are unaware of the specia/ procedur�s, inst►uctions/regulations can be obtained by contacting the Minnesota Pollution Control Agency (MPCA) at the address or phone number listed below. 6. Description of procedure to be followed in the event that unexpected RACM is found or Category II nonfriable ACM becomes crumbled, pulverized or reduced to powder: We will immediately stop work in the area apply water restrict access and notiiy the owner. 7. Demolition waste transporter(s) information: Transporter name: Rachel Contracting Contact name: Mark Kraemer Tranporter address: 4125 Napier Court NE City, State, Zip: St. Michale, MN 55376 Phone number: 763.424.1500 8. Demolition waste disposal information: Landfill name: Demcon Landfill OwnedOperator: Jason Haus Address/Location: 13020 Dem-con Drive City, State, Zip: Shakopee, MN 55379 Phone number: 952.445.5755 9. I certify that the above information is correct and I am a bonafide representative of the demolition contracto� or building owner and have authority to enter into agreements for my employer. Print name: Nick Bartemio Title: Senior Pro'ect Mana er Signature: �- Date: Important Note: Ensure you are in compliance with Minn. R. 7035.0805 prior to the commencement of renovation/demolition. This rule requires that the following items be removed two days prior to demolition: mixed municipal solid waste; household hazardous waste; industrial or hazardous waste; waste tires; major appliances; items containing elemental mercury, Poly- Chlorinated BiPhenyls (PCBs), and chlorofluorocarbons (CFCs); oil; lead; electronics; and other prohibited items. See MPCA Web site at http://www.pca.state.mn.us/publications/w-sw4-20.pdf for a Pre-Renovation/Demolition Environmental Checklist Guidance Document to assist with completion of this rule. Submit to: Minnesota Pollution Control Agency Questions call: 651-296-6300 or 1-800-657-3864 Industrial Division Fax: 651-215-1593 or 651-297-2343 520 Lafayette Road North St. Paul, MN 55155-4194 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in altemative formats w-sw4-21 • 7/ 16/09 Poge 2 of 2 S � 1 i �S � � • . y � �� TRANSMISSION REPORT 0 T430SYOU230 TIME FAX N0.1 NAME F670-A04 :08-05-'11 14:36 :763-424-1501 :Rachel Contracting N0. FILE N0. DATE TIME DURATION PGS TO DEPT MODE STATUS 574 297 08.05 14:22 00:50 4 16512151593 EC 602 OR �25/2011/MON 08;?7 AM LYON CONTAACTING FAX No,320-252-3603 P,002 � CITY OF �1tIDLEY 6431 University Ave NE Fridley MN 55432 (763)5�2-3604 FAX (�63)571-1267 MOVING [ ] DEMO (�� PERMIT APPLiCATION � REC'D �UG 0 9 201� Job Address :�� � /f'l�sr�s�� PP� S T �a�� 7�%V SSY.�7 Legal Description:�,���/e�Q`y,,,�► 3F��r�L�T�� ,gyn�rsQ's, di ir,n� �— TeJ.. Owner & Address : .�, . � ��,.���r,�� fyy�u � � su�c� � Contractor:��EL C.l�NT2,R{.Tlr�b- Tel. Address: �1�� q)�P►����.Miu����. nnN State Lxcense # DESCRIPTION OF BUII.Dni iG HOUSE : Length 3�. t Width 3Z• `1' Height 25 Sq, Ft . �,�5 Cu. GA.RAGE:Length ?.�,3� Width 1�.� Height � Sq, Ft. 31a Cu. , OTHER: Length Width Height Sq. Ft. Cu, Estimated Cost � Approx. Completion Date �b •� NOIt� ,(� #� • 4�15��Oo #�3. �f2N. ZS� Ft . �s, � aS' Ft . 33�4� F�. GOPi�R STATE ONE AT 651-454-0002 FOR UTILITY UTII�I Moving Routie: CTS , CALL ALL ��xov� ( s ) �Qv� �zox To =s svArrcE : MPCA: NOTIFICATION OF INTENT TO PERE'ORM A DEMOLITION (�/ YES () NO WATER AND SEWER DZSCONNECT PERMITS MUST BE ISSUED PRIOR TO LZE220LiTI0N. � � O Engineering O i e Mazsha ollect[$ ]Signature ons Conditions� ons a The undersi�ed heteby makes application for a pemzic m wreck/move the building descnbed above, agreeing to do all work ia suict a.�cordancc wirh the Ciry Ordinances a�d n�]iags of the Buildiag Division, and the State Code which requires a�ny water wall on tbc properry to be sealed by a Stare licensed water well driller, ar�d hereby declazes thac all f�acts sud represcatacions staoed in this app]ication arc nue and coaect. AT"i• DFMOLITON DEBRIS,INCLUDING FOUNDATYON & 6LAB, SHALL BE_REMOVED �'RO�I SI2"E. Date Movin Principle builcliing iwto Fridley . . . . Accessory building into Fridley . . . Through or withiri the City ..... Move a building out of Ciry ..... PERMrT FEE: Effective 01/O1/2011 Wrec � • $300. � For each 1, 000 cubic feet or fraction. .....$1.25 $ 42.00 For structures which would be impractical co .$ 20.00 cube, the fce shall bc based on thc totai cost ,$ 20.00 of wrec�ng at the rate of $6.00 for each $500.00 or fraccion. MIIV[MiJM $20,00 Office Use Or�: SAC-D form completed