Demolition Permit Application

Office use only Permit no.

Site address Date

Tenant/building name Suite/unit no.

I I I Applicant is Architect/engineer Contractor Owner Condominium no. Property owner

Name Phone

Address City State Zip Contractor Name

Address City State Zip

Contact person Phone Cell phone

EPA Lead Certification no. (Residential only) License no.

Architect/engineer

Name

Address City State Zip

Phone Cell phone Registration no. Class of work Check only one. I I I 1 Entire building I 2 Partial building 3 Complete tenant space 4 Partial tenant space Type of structure Check only one. I I 01 Single family residential 45 Recreational, amusement I I 02 Single family connected to single family 46 Other non-housekeeping shelter I I 03 Residential garage 65 Industrial buildings I I 30 Two family residential 70 Public works and utilities building I I 31 Three - four family residential 80 Public schools I I 32 Multiple - family residential 81 Private schools I I 40 Offices, banks, professional 85 Churches and religious buildings I I 41 Stores, restaurants, warehouse 88 Hospitals and institutional buildings I I 42 Hotels, motels 93 Other non-residential building I I 43 Parking garage 95 Fences, signs, antennas I I 44 Service stations and repair garage 96 Other non-building structures Continue to page 2

Community Development Building and Inspection PH 952-563-8930 BloomingtonMN.gov 04/15 1800 W. Old Shakopee Road FAX 952-563-8949 web 53_010 pg1 of 2 ( ) Bloomington MN 55431-3027 TTY 952-563-8740 Project details

Estimated completion date ______Job valuation $ ______

Description of work to be done ______

______

______I I Is this structure being removed to allow for the construction of new structure? Yes No I I DoeIsf yperso,p coosnetadc wt tohrek Sintavtoel voef Mthinen reesmootav Eale ovfa atonry U enliet vaat t6o5r1s-,2 e8s4c-5a8la4t6o. rTsh oer Csiitmy iolaf rB mloeocmhinagntiosnm ms? ay not issuYee sa demoNlio tion permit until the state has given approval.

I I Is thAelrl ew ae lwlse mll(uss)t obnes liotcea? ted and sealed before the start of demolition. Yes No

I I Will there be any changes made to the current plumbing system/fixtures? Yes No I I Will there be any changes made to the current electrical system/fixtures? Yes No I I Will there be any changes made to the current HVAC system/fixtures? Yes No I I Is erIof yseiosn, h caosn tthreo lC rietyq oufi rBeldo? omington Engineering Division been notified to inspect? I Yes I No For more information, please call Engineering at 952-563-4870. Yes No

Please read and sign

I hereby apply for a demolition permit and I acknowledge that the information above is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Bloomington and with the Minnesota Building Codes; that I understand this is not a permit but only an application for a permit and work is not to start without a permit; that the work will be in accordance with the approved plan in the case of all work which requires review and approval of plans.

______Applicant’s printed name ______Applicant’s signature ______Date

Do not write below this line

I I Utilities Required? Yes No Division I I approval Received? Yes No By ______Date ______I I Engineering Required? Yes No Division I I approval Received? Yes No By ______Date ______I I Environmental Required? Yes No Health I I approval Received? Yes No By ______Date ______

Inspector no. ______Case no. ______

Conditions of issuance ______

______

Permit approved by ______Date ______

04/15 web 53_010 ( ) pg 2 of 2