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Permit # 2017- 60515 <br />BUILDING PERMIT APPLICATION <br />Date Submitted: <br />Date Applicant Notified: <br />2401 Mounds View Boulevard <br />Mounds View MN 55112-1499 <br />(763)717-4020 Fax (763)717-4019 <br />Email: Permits ci.mounds-view.mn.us <br />Property Information <br />Property Address: <br />5102 (4 Or, <br />Bldg./Suite/Location (commercial projects only): <br />Owner Name: <br />Owner Phone Number: <br />air l So <br />Email Address: <br />Owner Cell Number: <br />Mailing Address: <br />City: State: <br />kt 006- 1,/ <br />Zip: 55 <br />Applicant/Contractor Information <br />Applicant Type: ['Primary Owner (Owner Affidavit Form Required) Contractor; License # <br />❑ EPA Certified Lead Renovation Firm <br />Company Name (contractors only): <br />C-6 Mr t11, ST O <br />Mailing Address: <br />Contact Name: <br />L <br />Property Use <br />Sl <br />Company Email Address: <br />M1 Sw�►• <br />City: <br />ctiMutUrtsv <br />❑ COMMERCIAL <br />❑ ED/INST/RELIG <br />❑ GOV/PUB/FAC <br />❑ DUP/TRUQUAD <br />X MFG HOME <br />❑ MULTI-FAM (+5) <br />❑ SINGLE_ FAMILY <br />❑ TOWN HOUSE <br />Project Details <br />4.. r 1Q, G r-ovtj <br />al <br />Yes / No <br />❑ Verified <br />❑ Verified <br />• -F-. can <br />State: <br />Contact Fax Number: <br />Construction Type (See back page for Descriptions and Fees) <br />❑ MANUF. HOME INSTALL <br />❑ NEW CONSTRUCTION <br />❑ ADDITIONS/REMODEL <br />❑ BASEMENT <br />DECK <br />DOORS/WINDOWS <br />❑ ROOF <br />❑ SIDING <br />❑ FENCE/KENNEL <br />❑ ACCESS. BUILDING <br />❑ RETAINING WALL <br />• SWIMMING POOL <br />❑ DEMO <br />❑ DRAIN TILE <br />❑ OTHER <br />*** COMPLETE <br />DESCRIPTION OF <br />WORK*** <br />Describe Work: <br />k)otk _ StiS of Sickirs <br />Are There Special Approvals (i.e. variances, CUP's, etc.) or Details of this Project: <br />IMPORTANT NOTICE: This permit becomes null and void if <br />work or construction authorized is not commenced within 180 days, or <br />if construction or work is suspended or abandoned for a period of 180 <br />days at any time after work has commenced. By signing this <br />application, you hereby certify that you have read and examined this <br />application and know the same to be true and correct. All provision of <br />laws and ordinances governing this type of work will be complied with <br />whether specified herein or not. The granting of a permit does not <br />presume to give authority to violate or cancel the provisions of any <br />other state or local law regulating construction or the performance of <br />construction. Applicant takes full responsibility for all work performed. <br />Applicant is responsible for all plan check fees if permit is cancelled or <br />withdrawn. <br />�v 1 77/ <br />� I <br />Applicant Signatufa /Dat <br />Project Value: (including labor and materials) <br />Permit Fee <br />See current fee schedule <br />State Surcharge <br />0005 x PROJECT VALUE <br />State Surcharge <br />Fixed fee $1.00 — Fix Fee Permits <br />Residential License Check <br />Fee $5 - state licensed contractors only <br />Last Revised FEBRUARY 2017 <br />