Permits - Permit# 3-24-17 - 2494 Black Lake Road - 1/1/2017 (4)CITY OF SPRING PARK
PAGE 1 BUILDING PERMIT
4349 Warren Avenue
Spring Park, MN 55384 O Handout Given
Phone: 952-471-9051 Fax: 952-471-9180 I] Lead Handout Given
SITE ADDRESS: 1 9LA c+- L A I f K D. -
PID: - Z3 - Z ` A01 3
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 220 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 o, you MUST Attach Certification Information, NO ❑ complete line 5)
6) EPA Contractor Certification Number: NAT -(applies to contractor only)
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PROPERTY OWNER: .r� F (rLL Address:
City: c. ,. State: Zip: . S3 2- Email: "a _ ��U t&E AL_ .
Contact Name: Phone:
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CONTRACTOR: S ry E rip .I-.LL, Address: S £
city: rt}' State: Zip: Phone: vat, Fax:
Contractor License No: E, C S 4 315- Contact Name: a Al irc LLPhone: ' f 2--1
Email: AJa e i
ARCHITECT: kL I; 1-4, Address: 1
Ci State: Zip:3 Phone: 7 43- Fax: L' 3- 822
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Email: (Z ® per N D E5 V . C u Contact Name: (IL-F"hone:-
TYPE OF WORK: )kNew, Construction ❑ Deck ❑ Re -Roof
❑ Commercial Residential ❑ Change of Use " % o Pool ❑ Re -Side
EST. VALUATION OF WORK ❑ Finish Basement ❑ Retaining Wall ❑ Fence
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$ 7-< 000 ❑ Remodel ° ❑ Porch ❑ Shed
Square feet: ❑Addition �0emolition ❑Window/Door Replacement
3 ❑ 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
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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. 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 an ordinances of the Municipality
and the laws of the State of Minnesota regarding actions taken pursuant to this permit. 1 agree to pay all plan review fees even If 1 choose not to proceed with the worts. Permit expires when work
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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,
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will be subject to a penalty.
Noise Ordinance In Effect: MONDAY - FRIDAY Before 7 a.m. and after 10 P.M. Weekends/Holidays before 7 a.m. and after 8 p.m.
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SIGNATURE OF APPLICANT: /: A 1 . i ;. DATE: 3.74 . •.' }
PRINTED NAME: t, J owm f+'c Lk£ This is the signature of: ❑ Owner or X Owner's Representative
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: $2,485
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Copy Charge ($.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 $
Plumbing Fee (from Page 2) $ 'NOTE: Commercial plans will be submitted to the Met Council Environmental Svcs
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for SAC determination. Escrow payment will be required when permit Is Issued. If
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:
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
5 cAL PERMIT
❑ PLAJWM PERMIT
PAGE 2
FOR PERMIT ISSUANCE
PAGE t and PAGE 2 should be cor pie
NIECHANICAL
INFORMATION
Msdtmrical Contraelor 'z O
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C State: ss
Phone• /a - —lfhFs 4 -y ( Q
Bond No: ft 00 31 9k
ICWdM Nerne;
Emall: l
ConInd phone; 6
of Waft gqIl*jdr de
_ 05 �
,
Val
Induade type of Project, focdues. and Gas Lines you wig be Instalft or replacing (include count far each type of facture):
AW-CHAAW LL FOCrIAWS
GAS Lam
urnace _I Kldm Fan
Furnace
ir' Cow System _� Bath Fen
Fireplace
ir Bmhanger Grill
�_ Unk Heater
Famity
Fireplace
Wdw Heater
nit Heller
/ Grm
n Floor Heat
/ pryer
m
lacerrant tone tixhrre only, no pfptng or vent changes)
Pend! Fee: $
Gas Line Pennit Fee: $
New Cordon
Stets : s
Boom
Other: i
Toed Nammeal Pie ft _
PLUMBING
Cadoe:
INFORNIATION
Add
State
Phone; FWc
Plumbers Lioenae Nx
Stella Bald fb;
ntacl Nerve:
Canted Phase:
Ostalled a Work:
Inmate type of project and fbdum you
wgizD ill E or replacing Ceade Count for ech type of fodure):
PLUMOMViahw
Heater Sham
Laundry Tub
o Ell Dishwasher
Rough4n Future Fbdrne
Water Softener Clothes Washer
SU"p
Laura SpriMd�er Sim Ice Maker Line
r1r3i
Wrier Pon System
Water Closet (Totl®q Hose eb
p� p�
Basin 8sthAib
piacernard tone lbdtae ordy, no pfpfrp or vent cttactges)
Pkrmbirtg PemUt Fee: :
ad
ate Sundwp $
n New Condnrcdnn
oawr: $
o Other
Tatal Plumbing Permle i
CITY OF SPRING PARK ❑ MECHANICAL PERMIT
❑ PLUMBING PERMIT
PAGE Z FOR PERMIT ISSUANCE
PAGE 1 and PAGE 2 should be complete
MECHANICAL INFORMATION
Mechanical Contractor: Address:
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 FD(TURES GAS LINES
Quanitv Quanity Quanity
Furnace Kitchen Fan Furnace
Air Conditioning System Bath Fan Fireplace
Air Exchanger Grill Unit Heater
Fireplace Water Heater 74, Oi?0 13 :
Unit Heater Grill
In Floor Heat Dryer
Gas Log Stove
Ol1ke Use Only:
❑ Replacement (one fixture only, no piping or vent changes) Mechanical Permit Fee: $
❑ Addibon/Remodel Gas Line Permit Fee: $
❑ New Construction State Surcharge: $
❑ Other Other. $
Total Mechanical Permit: $
•LUMBING 'INFORMATIO
Plumbing Contractor. 5 art Aumbi,?Q Address: 13ua5 6tc! t tvtkx ,- 07,✓e Si -&—H/
C' OV r S State: MJV Zip: 3 q Phone: Fax: 0 3 - ya k - I73 3
Plumbers License No: P/Y> D !P 13N1-/
State Bond No: /n8 6 0 3 a L a -
Contact Name: en l- 12a k f,-
lContact Phone:
Email:�t Sif�vurt lUmbir���nc.�et
Detailed Description of Work:
Indicate type of project and fixtures you will be installing or replacing (include count for each type of fixture):
PLUMBING FD(TURES
uan C3,uanittL Quanity
I_ Water Heater _ _ Shower �_ Laundry Tub
o 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 L_ Floor Drain
7 Lavatory Wash Basin c� 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: $