Permits - Permit# 18-54 - 2425 Black Lake Road - 1/1/2018 (3)CITY 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
Bt0.c-, Late- `2PID:
SITE ADDRESS: c
1) Was the home constructed before 1978? (YESA continue with line 2, NOIDcontinue without completing EPA Section)
2) Will the work disturb >_6 sq ft of interior painted surfaces or >_20 sq ft of exterior painted surfaces? (YESXgo to line 4, NO ❑ line 3)
3) Are there any windows being replaced? (YES)iC go to line 4, NO ❑ continue without completing EPA Section)
4) Has this home been Certified Lead Free? (YES ❑, you MUST Attach Certification Information, NOptcomplete line 5)
5) EPA Contractor Certification Number: NA - '--615 -a
(applies to contractor only)
!
PROPERTY OWNER: 0AC (k ,* ZS�-,$ S�
Address:
Ci : State: Zip:
Email:
Contact Name:
Phone: - to --
•
CONTRACTOR: U' n
Address: t
City: State: Zip:
Phone:1LP 4 pIP3 I Fax: -16 3 4 ED
Contract- icense o: C �-Zto 5 5 5
Contact Name:
Phone: If ID9� S p
Email: &Qwr\cQ hbIdmo.ccm
ARCHITECT:
Address:
City: State: Zip:
Phone: Fax:
•
Email:
Contact Name: Phone:
TYPE OF WORK: ❑ New Construction
❑ Deck ❑ Re -Roof
❑ Commercial XResidential ❑ Change of Use
❑ Pool ❑ Re -Side
EST. VALUATION OF WORK ❑ Finish Basement
❑ Retaining Wall ❑ Fence
$ no emodel
❑ Porch ❑ Shed
fee
Square ❑ Addition
❑ Demolition ❑ Window/Door Replacement
V ❑ Garage-Attached/Detach
❑ Plumbing -provide detail on Page 2 # being replaced
Detailed Description of Work: ❑ Accessory Structure
❑ Mechanical -provide detail on Page 2 ❑ Misc Other
•
Signature of this application by the legal property owner or a licensed contractor, as the owner's representative, is required and authorizes the Zoning Administrator or designee and the Building Official
or designee to enter upon the property to perform needed inspections. Entry, may be wit ut prior notice. I hereby acknowledge that I have read this application and state that all information is true and
correct to the best of my knowledge. I further agree that all work performed will be in co dance with approved plans, specifications and conditions and to abide by all ordinances of the Municipality
and the laws of the State of Minnesota regarding actions taken pursuant to this pe t. I ree to pay all plan review fees even if I choose not to proceed with the work. Permit expires when work
is not commenced within 180 days from date of permit, or if work is s ended, ab ndo , or not inspected
for 180 days. Work beyond the scope of this permit, or work without a permit or inspection,
•
will be subject to a penalty.
Noise Ordinance In Effect: MO - FRID B or 7 a.m. and after 10 p.m. Weekends/Holidays before 7 a.m. and aft r 8 p.m.
SIGNATURE OF APPL
DATE: O7�
PRINTED NAME:
This is the signature of: ❑ Owner or ❑ Owner's Represe tative
OCCUP. TYPE: CONST. TYPE: 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: $
*2016 SAC Escrow: $2,485
Copy Charge ($.25 per 8.5 x11 page) $
Other: $
J
Z
License Check ($5) / Lead Check ($5) $
TOTAL DUE: $
W
SUB -TOTAL $
N
D
Plumbing Fee (from Page 2) $
"NOI F: Commercial plans will be submitted to the Mel 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.
U
LL
Special Conditions/Required Setbacks:
LL
O
Building Approval By:
DATE:
Printed Building Approval By:
❑ License Verification ❑ Lead Verification - Checked By:
City Approval By:
DATE:
Paid: Date: Receipt No.
By:
CITY OF SPRING PARK ❑ MECHANICAL PERMIT
❑ PLUMBING PERMIT
PAGE 2 FOR PERMIT ISSUANCE
PAGE 1 and PAGE 2 should be complete
MECHANICAL INFORMATION
Mechanical Contractor: Address:
City: State: Zip: Phone: Fax:
State Bond No:
Contact Name:
Email:
Contact Phone:
Detailed Description of Work:
Indicate type of project, fixtures, and Gas Lines you will be installing or replacing (include count for each type of fixture):
MECHANICAL FIXTURES GAS LINES
Quanity Quani Quanity
Furnace Kitchen Fan Furnace
Air Conditioning System Bath Fan Fireplace
Air Exchanger Grill Unit Heater
Fireplace Water Heater
Unit Heater Grill
In Floor Heat Dryer
Gas Log Stove
Office Use Only:
❑ Replacement (one fixture only, no piping or vent changes) Mechanical Permit Fee: $
❑ Addition/Remodel Gas Line Permit Fee: $
❑ New Construction State Surcharge: $
❑ Other Other: $
Total Mechanical Permit: $
PLUMBING INFORMATION
Plumbing Contractor: Address:
City: State: Zip: Phone: Fax:
Plumbers License No:
IState Bond No:
Contact Name:
I Contact Phone:
Email:
Detailed Description of Work:
Indicate type of project and fixtures you will be installing or replacing (include count for each type of fixture):
PLUMBING FIXTURES
Quanity Quanity Quanity
Water Heater Shower Laundry Tub
❑ Gas ❑ Electric Dishwasher Rough -In Future Fixture
Water Softener Clothes Washer Sump
Lawn Sprinkler System Ice Maker Line Water Piping System
Water Closet (Toilet) Hose Bib Floor Drain
Lavatory Wash Basin Bathtub
Office Use Only:
❑ Replacement (one fixture only, no piping or vent changes)
Plumbing Permit Fee: $
❑ Addition/Remodel
State Surcharge $
❑ New Construction
Other: $
❑ Other
Total Plumbing Permit: $