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P - 48183�.i i Y vr r ltlilL H; Y 6431 University Ave NE Fridley MN 55432 (763)572-3604 FAX (763)571-1287 MUVINU � ] DEMO'�,PERMIT APPLICATION Job Address: �'?IpS i��lss�� P�� Sfi n� Legal Description: ,v Owner & Address : �� }�-��- Tel . # Contractor: Address: �� erS, w�.-, S53�CRI] HOUSE: Length �Z Width Zz.-- State License # 'ION OF BUILDING Height �f Sq. Ft. Tel. #� ZZ-iZ Cu. Ft. `��i" GARAGE.Length �_ Width Z y Height % Sq. Ft. Cu. Ft. J�� OTHER: Length Width Height Sq. Ft. Cu. Ft. Estimated Cost $�� Q(� Approx. Completion Date �� CALL GOPHER STATE ONE AT 651-454-0002 FOR UTILITY LOCP,TIONS. CALL ALL UTILITIES FOR DISCONNECTS BEFORE WRECKING MOVING STRUCTURE. Moving Route: APPROVAL(S) REQUIRED PRIOR TO ISSUANCE: MPCA:-NOTIFICATION OF INTENT TO PERFORM A DEMOLITION YES D - � , , i �,. . �y � i �� : �M� , ��* s • - • a: '� �, � � ,;� .� � � � R - - - • - �� . . - • - �►�-�� L ��_ ' i � ' �-lt�•i. ,: E ��/ r ■❑ �icia Engineering Conditiofis Conditions, ❑ Fire Marshal Conditions The undersigned hereby makes application for a pernut to wreck/move the building described above, agreeing to do all work in strict accordance with the City Ordinances and rulings of the Building Division, and the State Code which requires any water well on the ' property to be sealed by a State licensed water well driller, and hereby declazes that all facts and representations stated in this application ' are true and correct. ALL DEMOLITON DEBRIS, INCLUDING FOLTNDATION & SLAB, SHALL BE REMOVED FROM SITE. ��i31/l� � Date _ Sign� 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 Wreckin� For each 1,000 cubic feet or fraction. .....$1.25 For structures 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. r .� PERMIT FEE: � MINIMUM $20.00 Office Use Only: SAC-D form completed Effect' O1 /O1/2011 � �j � � �� ive � �� CT � �. ��i� � RECro Nov o � 20�� s , . . . �� - Minnesota Pallution Not�f�cat�on of I ntent to � Control Agency 520 Lafayette Road North Pe rform a Dem o li ti on St. Paul, MN 55155-4194 Asbestos Program Doc Type: Notification 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: Veit & Company, Inc. Building name: Address: 14000 Veit Place Address/Location: 465 Mississippi Street NE City, State, Zip: Rogers, MN 55374 Phone number: 763-428-2242 Contad name: Jessica Anderson Phone number: 763-428-2242 City, State, Zip: Fridley, MN 55432 County: Anoka Phone number: N/A Age of bldg (yrs): 40 Size of bldg (sq ft): 1,144 Number of floors, including basement level(s): 2 Building Owner Present use of bldg: Vacant Name: Fridley HRA Prior use of bldg: Residental Address: 6431 University Ave NE City, State, Zip: Fridley, MN 55432 Phone number: Contact name: Jeannie Benson Phone number: 763-572-3552 Dates of demolition or intentional burning: Start date: 11/7/11 End date: 11/18 /11 mMdd/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 Pertorm 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 Square feet Cubic feet Category I nonfriable ACM means asbestos-containing packings, gaskets, resilient floor covering, and asphalt roofing products containing more than one percent asbestos. Category I nonfriable ACM is not allowed to remain in place for demolition if it is in poor condition. Category II: Linear feet Square feet Cubic feet Category II nonfriable ACM means any material, exduding Category I nonfriable ACM, containing more than one percent Asbestos that, when dry, cannot be crumbled, pulverized, or reduced to a powder by hand pressure. Category II nonfitiable 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). 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 • 7/9/f0 Poge 1 of 2 2.� Aescription and location of ACM remaining in place (including number of floors and rooms): 3. Company and/or individual that conducted the buiiding inspection and the procedure used to determine the presence or absence of ACM (including analytic method): (Note: Prior to demolition all stnactu�s must be inspected by a licensed asbestos inspector who has been certified through the Minnesota Department of Health.) EMSL Analytical Inc. usin the PLM method. 4. Description of planned demolition and the specific method(s) that will be used: Loading of debris using a hydraulic excavator. 5. If the demolition was ordered 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 demolition must be submitted as early as possib/e before demolition begins, but not later than the following woricing day. A demolition is conside►ed an eme�ency on/y when the facility has been deemed stn�ctura/ly unsound and in danger of imminent co/lapse. If the structurally unsound building is known to contain any ►egulated ACM or is suspected to contain any �egulated ACM, specia/ proceduies must be followed. If you a� unaware of the specia/ procedunes, instroctions/ regu/ations can be obtained by contacting the Minnesota Pollution Control Agency (MPCA) at the add�ss or phone numberlisted 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 shut down the project; we will keep subject material moist and contact the owner, regulatory agents, and abatement contractor for action. 7. Demolition waste transporter(s) information: Transporter name: Veit & Company, Inc. Contact name: Vaughn Veit Tranporter address: 14000 Veit Place Ciry, State, Zip: Rogers, MN 55374 Phone number: (763)428-2242 8. Demolition waste disposal information: Landfill name: Vonco II Demolition Debris Landfill Owner/Operator: Steve Halgren Address/Location: 15301 140'" Ave SE City, State, Zip: Becker, MN 55308 Phone number: _ (763)262-8662 9. I certify that �e above information is correct and I am a bonafide representative of the demolition contractor or building owner and have authority to enter into agreements for my employer. Print name: Jessica Anderson Signature: Important Note; Title: EstimatodProject Manager Date:10/24/11 � Ensure you are in compliance with Minn. R. 7035.0805 prior to the commencement of This rule requires that the following items be removed iwo days prior to demolition: mixed municipal solid waste; ho sehold 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. S MPCA Web site at www.pca.state.mn.us/publications/w-sw4-20.pdf for a P►e-Renovation/Demolition Environmenta/ Checklist G'dance Document to assist with completion of this rule. Submit to: Minnesota Pollution Control Agency Questions call: 651-296-6300 or 1-800-657 Industrial Division — Asbestos Program 520 Lafayette Road North Fax: 651-297-1438 St. Paul, MN 55155-4194 E-mail: asbestos.demolition.pca@state.mn.us www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in a w-sw4-21 • 7/9/ f0 :ive formats Page 2 of 2