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<br />/' <br /> <br />~SfflIbbE ~/ <br /> <br />COMMUNITY DEVELOPMENT DEPARTMENT. PHONE: 651-490-2238 . FAX: 651-490-29~ <br />RESIDENTIAL BUILDING PERMIT APPLICATION <br /> <br />Addres~ Of;,. <br />~Ylq <br />Lot (Optional): L-DT '2.'3 <br /> <br />APPLICANT: Name:Ba.A1:J l-\of=t== <br />tB q~ S~hWC1 1StYtt:{-+ <br />+\ow <br />S \--\A-oV\1;ffiL4- <br />:8'00 LE .t:~ L- <br />I20Gtt~f{)<L\) M~ <br />$ 5000- <br /> <br /> <br />WORK PROPOSED: <br /> <br />APPLICATION DATE: <br /> <br />SITE: <br /> <br />Address: <br /> <br />OWNER: <br /> <br />Address: <br /> <br />Address: <br /> <br />PERMIT NUMBER: Ae 1-~'J-,gJ- <br /> <br />o New <br />o Deck <br />o Window <br /> <br />o Alteration <br />o Roof/Siding <br />o Draintile <br /> <br />o Addition 0 Garage <br /> <br />o Grading (see supplement) 0 Demolition <br /> <br />Other:f="~~ 'f2.(e'P<.l\-~-w\tN\ <br /> <br />@wt L .i-~ ''UJO 1- <br />C;,i+M) U\ ,&:~,{..\- A-Ve <br /> <br />Block (Optional : <br /> <br /> <br />Subdivision (Optional): <br /> <br />Phone:(oSi-_% 3-9 C( 00 <br /> <br />(dS-\. - '-tSv~44-oD <br /> <br /> <br />hv'2t \>Dlt C:::j\. <br />VALUATION (labor & materials): <br /> <br />/ 1 ) <br />u:::uA{L, WovD N::1J <br /> <br />WORK DESCRIPtION: RE? <br />~~ \h~UL <br /> <br /> <br />INDICATE SQUARE <br />FOOTAGE OF: <br /> <br />1 st floor: <br />2nd floor: <br />3rd floor: <br /> <br />Basement: <br />Garage: <br />Deck: <br /> <br />Porch: <br />#of Stories: <br /> <br />Acknowledgement and Signature: <br />The undersigned hereby makes application to the City of Roseville to perform the work as herein described. The undersigned further states, under penalty of <br />law, that the work will be performed in accordance with the Minnesota State Building Code, this application, and any approved plans and/or specifications. <br /> <br />Pont Name: ~(lu ci f-{OFf Signature: t~ <br />~ ,~,.. C.,'C::i ~\ . , <br />o Contractor 'ib Owner 0 Architect Phone: 0bi~4<O ,. l laU Date: dj:i&~'L <br /> <br />OFFICE USE ONLY: <br /> <br />o Electrical <br /> <br />o Mechanical <br /> <br />o Plumbing <br /> <br />o Water <br /> <br />o Sewer <br /> <br />SEPARATE PERMITS REQUIRED: <br /> <br />FEES: <br />Permit <br />State Surcharge <br />Plan Check <br />Cert. of Occup. <br />Metro SAC <br /> <br /> <br />Water Meter (# <br />Construction Deposit <br />Contractor's License <br />Assessments <br />Park Dedication <br />Other: <br /> <br />$ <br />$ <br />$ x.x:x-kX <br />$ <br />$ <br />$ <br /> <br />Total Fees: $ <br />Receipt #: <br />Receipt Date: <br /> <br />$ <br />$ <br />$ <br />$ <br />$ <br /> <br />/" <br />j I (;L5 <br />, ;},)O <br /> <br /> <br />sure to contact public utilities for location of underground cables, <br />conduits, pipes, etc. before digging. <br />Call Gopher State One: 651-454-0002 <br /> <br />