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� --� � � COMMUNITY DEVELOPMENT 2660 Civic Center Drive •3 Roseville, MN 551 ] 3 Phone:(651)792-7005 ❖ Fax:(651)792-7070 SETBACK PERMIT APPLICATION CITY CODE SECTION 1013.05 www.ci.roseville.mn.us pC�C�L�OdL� � A��oos �y .. � G� APPLICATION FEE: $75 (Fee should be made payable to Ciry of Roseville upon submittal of completed application.) Please complete the application by typing or printing in ink. Use additional paper if necessary. 1. Property Owner Information: Last name: Theisen Address: 2034 Cleveland Ave N Phone number: 612-281-0573 First name: Jeff City/State/Zip: Roseville, MN 55113 Email address: jeff@jefftheisen.com 2. Applicant Information: (f different from above) Last name: Add��ess: Phone numbe�°: First name: City/S1ate, Zip: Email address: 3. Statement of Intent: Briefly describe what will be done on the property requiring the Setback Permit. Add a 2 storv addition to the north wall of the home on a concrete block foundation with a crawl space. The foundation size of the addition would be approximately 7 feet by 23 feet. The addition enters into the current setback approximatel 3 feet to the north 4. Additional Required Information: a. Proposed Plans: A scaled site plan showing the existing and proposed building footprints as well as driveways, sidewalks, and patios is required. Simple elevation drawings showing the proposed addition or new building will also be required if the Setback Permit request doesn't apply exclusively to a driveway. The plans for may be on 8%2"x 11" or 11 "x 17" paper. b. Written Narrative: The written narrative should address the 12 criteria that must be considered during review of Setback Permit applications; these criteria are listed in the document attached to this application and in § 1013.05 of the City Code. 5. Signature(s): By signi correct to the best of y� Property Owner: Applicant: , f ou `�ttest that the information above and attached is true and Date: � - Z v � Date: