Permits - Permit# SP15-040 - 2452 Black Lake Road - 1/1/2015CITY OF SPRING PARK
BUILDING PERMIT
PAGE 1
4349 Warren Avenue
❑ Handout Given SP/S- O -/O
Spring Park, MN 55384
Phone: 952-471-9051 Fax: 952-471-9160
❑ Lead Handout Given
SITE ADDRESS:
PID:
1) Was the home constructed before 1978? (YES ❑, continue with line 2, NO ❑ continue without completing EPA Section)
2) Will the work disturb z6 sq ft of interior painted surfaces or a20 sq
ft of exterior painted surfaces? (YES ❑ go to line 4, NO ❑ line 3)
3) Are there any windows being replaced? (YES ❑, go to line 4, NO ❑ continue without completing EPA Section)
4) Has this home been Certified Lead Free? (YES ❑, you MUST Attach Certification Information, NO ❑ complete line 5)
5) EPA Contractor Certification Number: NAT -
(applies to contractor only)
PROPERTY OWNER:
Il
Address: Y
Ci : tl tate: i L
Email: e2 AV A'
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Contact Name:
Phone:
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CONTRACTOR: t
Address: S500 G✓ oZ
Ci : 4i 4Gi. V'S State: hJL, Zip:
Phone: Fax:
•
Contractor License No:
Contact Name: Phone:
•
Email: c�ei o
ARCHITECT:
Address:
City: State: Zip:
Phone: Fax:
•
Email:
Contact Name: Phone:
TYPE OF WORK: ❑ New Construction
❑ Deck ❑ Re -Roof
❑ Commercial esidential ❑ Change of Use
❑ Pool )(Re -Side
EST. VALUATION OF WORK ❑ Finish Basement
❑ Retaining Wall ❑ Fence
$ 6D dri e, ❑ Remodel
❑ Porch ❑ Shed
•
Square feet: ❑ Addition
❑ Demolition ❑ Window/Door Replacement
❑ 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 without prior notice. 1 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 accordance 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 permit. I agree to pay all plan review fees even If I choose not to proceed with the work. Permit expires when work
.4
is not commenced within 180 days from date of permit, or it work is suspended, abandoned, or not
inspected for 180 days. Work beyond the scope of this permit, or work without a permit or inspection,
•
'II be subject to a penalty.
Noise Ordinance In Effect: MOND FRIDA efor a.m. and after 10 p.m. Weekends/Holidays before 7 a.m. and after 8 p.m.
SIGNATURE OF APPLICANT:
DATE: G —
PRINTED NAME: L ��
This is the signature of: ❑ Owner or-d-lIQbwner's Representative
OCCUP. TYPE: CON T. TYPE: CODE:
BLDG SPRINKLED Yes / No
VALUATION: $
Permit Fee: $ 3P. OO
WAC Charge: $
Plan Review Fee: $
Sewer & Water Hook -Up: $
State Surcharge: $ /, OD
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: $
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License Check ($5) / Lead Check ($5) $
TOTAL DUE: $ 10
-�9.
SUB -TOTAL $
y
n
Plumbing Fee (from Page 2) $
*NOTE: Commercial plans will be submitted to the Met Council Environmental Svcs
for SAC determination. Escrow payment will be required when permit is issued. If
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Mechanical Fee from Page 2 $
after Met Council review no SAC is determined, escrow will be refunded in full.
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Special Conditions/Required Setbacks:
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Building Approval By:
DATE:
Printed Building Approval By:
❑ License Verification ❑ Lead Verification - Checked By:
City Approval By:
DATE:
Paid: Date: Receipt No.
By:
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CITY OF SPRING PARK
PAGE 1 BUILDING PERMIT
4349 Warren Avenue
Spring Park, MN 55384 ❑ Handout Given SP/S'- U' 0
Phone: 952-471-9051 Fax: 952-471-9160 ❑ Lead Handout Given
SITE ADDRESS: PID:
1) Was the home constructed before 1978? (YES ❑, continue with line 2, NO ❑ continue without completing EPA Section)
2) Will the work disturb z6 sq ft of interior painted surfaces or Z20 sq ft of exterior painted surfaces? (YES ❑ go to line 4, NO ❑ line 3)
3) Are there any windows being replaced? (YES ❑, go to line 4, NO ❑ continue without completing EPA Section)
4) Has this home been Certified Lead Free? (YES ❑, you MUST Attach Certification Information, NO ❑ complete line 5)
5) EPA Contractor Certification Number: NAT - (applies to contractor only)
PROPERTY OWNER:
t Address: EZ <'
City: `111 fate: i ( Email:
Contact Name: Phone: �j
•
CONTRACTOR: J E Address: S 00
Ci : `4 t et , v j State: AILI Zip: Phone: ' " t 0 Fax:
Contractor License No: L Contact Name: Lt fAI-04 Phone:
Email: uG
ARCHITECT: Address:
City: State: Zip: Phone: Fax:
•
Email: Contact Name: Phone:
TYPE OF WORK: ❑ New Construction ❑ Deck ❑ Re -Roof
❑ Commercial Aesidential ❑ Change of Use ❑ Pool )(Re -Side
EST. VALUATION OF WORK ❑ Finish Basement ❑ Retaining Wall ❑ Fence
$ (2.-JIVE ❑ Remodel ❑ Porch ❑ Shed
Square feet: ❑ Addition ❑ Demolition ❑ Window/Door Replacement
❑ 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 owners representative, is required and authorizes the Zoning Administrator or designee and the Building Otricial
or designee to enter upon the property to perform needed inspections. Entry may be without 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 accordance 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 permit. I agree to pay all plan review fees even If I choose not to proceed with the work. Permit expires when work
u
is not commenced within 180 days from date of permit, or if work is suspended, abandoned, 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: MOND FRIDA �Befor a.m. and after 10 p.m. Weekends/Holidays before 7 a.m. and after 8 p.m.
SIGNATURE OF APPLICANT: DATE: — Ls -
PRINTED NAME: This is the signature of: ❑ Owner or-6,40wner's Representative
OCCUP. TYPE: CON T. TYPE: CODE: BLDG SPRINKLED Yes / No
VALUATION: $
Permit Fee: $ 31> 00 WAC Charge: $
Plan Review Fee: $ Sewer & Water Hook -Up: $
State Surcharge: $ /, 00 Sewer & Water Disconnect: $
Site Inspection Fee: $ Water Meter: $
S.E.C. Fee: $ Muni SE/WA Fee: $
Investigation Fee / Other Fee: $ *2015 SAC Escrow: $2,485
J
Copy Charge ($.25 per 8.5 x11 page) $ Other: $
z0
License Check ($5) / Lead Check ($5) $ TOTAL DUE: $
w
SUB -TOTAL $
to
D
'NOTE: Commercial plans will be submitted to the Met Council Environmental Svcs
Plumbing Fee (from Page 2) $
uJ
for SAC determination. Escrow payment will be required when permit is issued. If
Mechanical Fee from Page 2 $
V
after Met Council review no SAC is determined, escrow will be refunded in full.
LL
Special Conditions/Required Setbacks:
O
Building Approval By: DATE:
Printed Building Approval By: ❑ License Verification ❑ Lead Verification - Checked By:
FI'y
Approval By: DATE:
Paid Date: Receipt No. By: