Permits - Permit# 24SP-00050 - Extension - 2433 Black Lake Road - 7/14/2025REQUEST FOR EXTENSION
Permit Owner/Applicant: a,� 'AJ4A 170,Me
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Homeowner (if different than applicant): 'qL � rL, Po 01 kh
Site Address: �, q '�l A 1c t,k I,, h e j2 J. 5,,9 r,'n1, Pc, ( l\'
Contact Name: '1 A11c,Phone number:
Mailing Address (if different than site address): S !a� ��411 , �Je 16,,,U 1114 ST -3
Municipality:
Permit Number: ' ' 000Sb Type of Project: ke MOde- I
Brief explanation of why extension is being requested — mus be justifi ble ause per MN
Rules, Chapter 1300.0120 Subp. 11: (4 f Was c6 1GYe wC 4-o
lMo, 4c(,41 C 4c,ryeS �% 5%�ie61t- YN G�ELYS,
Date extension requested to: f4,,5 i 1�0 Z S
(Date cannot exceed 180 days from date of this fequest.)
SIGNATURE/DATE: li
Email address: t G n •�' `S "'� oc �i ViiCti 1 � p rn
1300.0120 subp. 11 Expiration: "Every permit issued shall become invalid unless the work authorized by the pen -nit is
commenced within 180 days after its issuance, or if the work authorized by the permit is suspended or abandoned for a
period of 180 days after the time the work is commenced."
Please call 952-442-7520 with questions.
Return to
EMAIL: info mnta'�,SAFEbuilt.corn MAIL: SAFEbuilt
235 First Street West
FAX: 952-442-7521 Waconia, MN 55387
DO NOT COMPLETE BOTTOM PORTION
Office Use Only------- -------- ----- --
Date request received in office: -7(l 1z11;--
Date permit issued: 7, G Date of last inspection: i
If previous extension in effect, date it expires
Date permit extended to: 12JI IZ,�
Approved by: Wy--- Date:
Approval notification given:
via:
https:llsafebuilt.sharepoint.comisites/MNspectFileShare/Shared Documentsl—Building Inspection ServicesfFonnslLetter
Templates/Extension/REQUEST FOR EXTENSION.doc Revised Mar-2018
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