Permits - Permit# 17-34 - 2478 Black Lake Road - 1/1/2017CITY OF SPRING PARK
PAGE 1 BUILDING PERMIT
4349 Warren Avenue
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Spring Park, MN 55384
El Handout Givenel-
Phone: 952-471-9051 Fax:(�9I5_2-n471-19160
❑^ Lead Handout Given
SITE ADDRESS: a.14 `1 % 4 �-f/,�- 1
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Y a PID:
1) Was the home constructed before 1978? (YES ❑, continue with line
2, NO Continue without completing EPA Section)
2) Will the work disturb >_6 sq ft of interior painted surfaces or 220 sq ft f exterior painted surfaces? (YES o go to line 4, NOline 3)
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3) Are there any windows being replaced? (YES ❑, go to line 4, NO
Voontinue 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)
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PROPERTY OWNER: r Y OL-fiQ,
Address: G-7 3
City: % ,- State: /t/jN Zip:
Email:
Contact Name: Laannw1
Phone: 6/j
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CONTRACTOR: j-alpwu� b t
Address: �i✓W S "J— 5�
Ci _^ : i,Pr av- State: 114Zip: SS
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Phone: to 12 - 10 — Z( Fax:
Contractor License No: [ % J
ontact Name:e4j, (y,..J o ,Phone: !a -,,270 - G l y
Email: _112ZiZ.
ARCHITECT:
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City: State: Zip:
Phone. Fax:
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Email:
Contact PONIX Phone:
TYPE OF WORK: New Construction
❑ Deck ❑ Re -Roof
❑ Commercial .residential ❑ Change of Use
❑ Pool ❑ Re -Side
ES VALUATION OF WORK ❑ Finish Basement
❑ Retainin Wall ❑ Fence
$ (} Q d-0 d ❑ Remodel
❑ Porch ❑ Shed
Square feet: ❑ Addition
3 �d
❑ Demolition indow/Door Replacement
❑ Garage-Attached/Detach
umbing-pro a detail on Pag # bet g replaced
Detailed Description of Wo ❑ Accessory Structure
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❑ nical-pro a detail on Pa , 2 ❑ Misc Other
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Signature of this application by the legal property own a licensed contrac as the owner's r
ntative, is required uthorizes the Zordhg Administrator or designee and the Building Official
or designee to enter upon the property to perform need eclions. Entry m be without prior
nolic ereby acknowledge have read this application and state that all information is true and
correct to the best of my knowledge. I further agree that all I performed will b accordance with appr plans, specification d conditions and to abide by all ordinances of the Municipality
and the laws of the Slate of Minnesota regarding actions taken uant to this - agre to
pay all plan 'ew fees even if I choose not to proceed with the work. Permit expires when work
is not commenced in 1110 days from date of permit, or it work is ed, a ne or not inspected for ays. Work beyond the scope of this permit, or work without a permit or inspection,
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will be subject to a pe
Noise Or nce In Effect: MO Y IDA fo and after 10 p.m. eekends/Holidays before 7 a.m. and after 8 p.m.
SIGNATURE OF APPL NT
DATE: L / %
PRINTED NAME:
his is the sign ure of: ❑ Owner orOwner's Representative
OCCUP. TYPE: CO TYPE: COD
BLDG SPRINKLED Yes N
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: $
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License Check ($5) / Lead Check ($5) $
TOTAL DUE: $
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SUB -TOTAL $
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Plumbing Fee (from Page 2) $
'NOTE'. Commercial plans will be submitted to the Met Council Environmental Svcs
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Mechanical Fee from Page
for SAC determination. Escrow payment will be required when permit is issued. If
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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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