Permit application - 4000 Sunset DriveCITY OF SPRING PARK
PAGE 1
BUILDING PERMIT
4349 Warren Avenue
Spring Park, MN 55384
❑ Handout Given
Phone: 952-471-9051 Fax: 952-471-9160
❑ Lead Handout Given
Route to MNSPECT
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SITE ADDRESS, —��(V`�
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PID:_ ��J�l��a3'3J
1) Was the home constructed before 1978? (YES ❑, continue with line
2, NO ❑ continue without completing EPA Section)
2) Will the work disturb 26 sq ft of interior painted surfaces or �20 sci ft of exterior painted surfaces? (YES ❑ go to line 4, NO ej line 3)
3) Are there any windows being replaced? (YES o, go to line 4, NO n COntintlP Wthout completing EPA Section)
4) Has this home been Certified Lead Free? (YES ❑, you MUST Attach Certification Information, NO o complete line 5)
5) EPA Contractor Certification Number. NAT -
(applies to contractor only)
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PROPERTY OWNER: .n, 1 E e l!l
Address:
,itv: f tat
Email:
'ontact Name:
Phone:
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CONTRACTOR: 7` trCP
^•�fAddress: I
17e State: : Zi
Phone: Z — % 0 Fax:
Contractor License No:
Contact Name r ne:
Email: n l+� vv�c�S�-I
4RCHITECT: �° [
Address:
City, State:
Phone: Fax:
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Email:
Contact Name: "' "'` Phone:
TYPE OF WORK: = New Construction
❑ Deck ❑ Re -Roof
Commercial sldential Change of Use
❑ Pooh ,� ❑ Re -Side
EST. VALUATION OF"RK Finish Basement
6 12 Q�0 w Remo:iel
❑ retaining Wall ❑ Fence
❑Parch ❑Shed
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Square feet _ Addition
c Demolition ❑ Window/Door Repiaet:ment
7 Garage-AttachedlDetach
= Plumbing -provide delay on Pape # being replaced
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Detailed Description of W rk: ❑ AccessoryStructure
_ Mechanical-r rn;,4e derail on Pace ,.-_ Misc other
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:110miture oftiolopoketim by the legal property owner or a Ikensed callliaetor, as the owfeers w Is uks d authortrae the Zoning AdmMbtrator or dedWm and the BuNding Oftlelal
cr designee to enter upon the property to psrlbrm needed Inspections. Erdry may be willrout prior
notice. I hereby acknowledge that 1 have read this applkatlon and state that all Information Is true and
correct to the bast of my knowledge. I Writer agree that ak work performed will be In accordance with approved plans, specnlcaaons are condnlons end to abide by al ordinances of the Municipallly
,nd the laws of the State of Mlnnresola regarding actions taken pursuent to this perms. l a" to
pay all plan review fees awn If i choose not to proceed with are work. Permit expires when work
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n not commenced within 160 days from dale of.pean0: or It work Is expended, abandoned, or riot Inspected for 180 days. Work beyond the scope orthls permit, or work without a permit or Inspection,
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,dtl be subject to a penally.
Noise Ordinance In. Effect_ MONDAY - FRIDAY Bef3o 7 94. and
after 10 .m. Weekends/Holidays before 7 a.m. and after 8 p.m.
SIGNATURE OF APPLICANT:
DATE:
I- !NTE^ KAME: - :Fj 4n j,
This is the signature of: E:l Owner or 7- Owner's Representative
OCCUP. TYPE: C0111ST. TYP : CODE:
BLDG SPRINKLED Yes / No
VALUATION: $ .
Permit Fee: $
WAC Charge: $
Plan Review Fee: $
Sewer & Water Hook -Up: $
State Surcharge: $
Sewer & Water Disconnect: $
Site Inspection Fee: $
Water Meter. $
S.E.C. Fee: $
Muni SE/WA Fee: $
Investigation Fee / Other Fee: $
SAC Escrow: $2.485
Copy Charge ($.25 per 8.5 x11 page) $
Other. $
Q
License Check ($5) / Lead Check ($5) $
TOTAL DUE: $
W
SUB -TOTAL $
H
0
Plumbing Fee (from Page 2) $
Commercial plans will be submitted to the Met Council Environmental Svcs
W
Mechanical Fee from Page 2 $
for SAC determination. Escrow payment will be required when permit Is Issued. if
after Met Council review no SAC Is determined, escrow will be refunded in full.
LLSpecial
Conditions/Required Setbacks:
O
Building Approval By:
DATE:
Printed Building Approval By:
❑ License Verification ❑ Lead Verification - Checked By.
City Approval By:
DATE:
Paid: Date: Receipt No.
By: