HomeMy WebLinkAboutBuilding Permit 5024-B-11
APPLICATION FOR DEMOLITION PERMIT
SCOTT COUNTY, MINNESOTA
1L
Address:
Contractor Name:
Address:
You must submit a site drawing showing: All buildings, wells, septic tanksldrainfield, petroleum tanks, property lines and setbacks.
I. Typeofbuilding(s) to be demolished: Old~;#( ~~ ~ e ~ v~_ a5,q~/r .)/~
Location of disposal site: ~.p n< - CC'JJ
2. Type of construction material: Wood ~ Masonry Other
3. Asbestos present in building: Yes _ No ~ If Yes, complete A & B below and notify the State, if required:
A. Name of contractor removing asbestos:
Date Received:
Permit No.: ,?'I) ;;''-/- IS - )/
Receipt No.: ..:) 7' I Rf5
Home Phone:
Work Phone:
Home Phone:
Work Phone:
Work Phone:
Township or City.
Project Address:
B. Facility disposal site: Name:
Address:
4. Indicate if any of the hazardous materials listed below are present. If Yes, include how they will be managed (use other sheets if needed).
Fluorescent lamps and ballasts: Yes _ No "..- ~
Mercury containing devices (thermostats, switches, appliances, boilers, etc.): Yes No L.---"
Electrical equipment containing PCBs, including light ballasts, capacitors, an~pplianceV Yes ~._
Appliances and fire extinguishers containing freon, CFCs, halon, etc. : Yes _ No ~
Other Hazardous Material (paints, pesticides, batteries, auto or cleaning products, etc.): Yes _ No V---"
5. Well(s) on site: Yes ---..!:::::::-. No _ If Yes, will wel
Licensed Well Contractor is: ~ V
6. Cistern on site: Yes No If Yes, the cistern must be p perly disposed/filled as directed by the Env. Health Dept.
7. Septic tanks(s) on site: Yes _ No t--1rYes, will tank(s) be abandoned? Yes _ No _ If Yes, complete below:
Tanks to be pumped by (licensed pumper name):
A. Tank(s) to be collapsed and filled with (sand, gravel, etc.): Yes No
or B. Tank(s) to be removed and disposed at:
8. City water & sewer: Yes _ No ~ (If Yes, must be properly abandoned.)
9. Underground petroleum storage tank(s) on site: Yes _ No ~. If Yes, will the tanks be used? Yes _ No_
If No, the Underground Storage tank(s) must be abandoned in accordance with State rules and regulations.
If Yes, the name of the
that the above information is correct and that I will abide by all federal, state and local requirements,
inin 0 building demolition and removal of hazardous materials, including the conditions listed below.
t!,.r;:O_
Contractor's Signature
Date
- - - - - - - - - - - - - - - - - - - - - - - - - - - COUNTY ENVIRONMENTAL HEALTH USE ONLY _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Approved: - Denied: _ By Scott County Environmental Health subject to existing regulations and the following conditions:
ALL SOLID WASTE MUST BE DISPOSED AT A LICENSED SOLID WASTE FACILITY. NO SOLID WASTE
~HALL BE ~~~ OR BURIED ON THE SITE. _ . . __ . _./
Signature ~ :--- ~--=2:5 Date c2 /0/"./ CJ ti?
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - COUNTY BUILDING OFFICE USE ONLY _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Approved: _ Denied: _ By the Scott County Building Official subject to existing regulations and the following conditions:
Signature
Additional Comments:
Date
FEES: Demolition Permit: d~ SO
State Surcharge
TOTAL FEE
, s:o
..:l ,-/, 00
Inspector's Copy (White) Township Copy (Canary) Applicant's Copy (pink)
r
t oJ