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<br />~Si3VIbbE <br /> <br />COMMUN1TYDEVELOPMENT DEPARTMENT. PHONE: 651-490-2238. FAX: 651-490-2931 <br />RESIDENTIAL BUILDING PERMIT APPLICATION <br /> <br />WORK PROPOSED: <br /> <br />o New <br />o Deck <br />o Window <br /> <br /> <br />4 I -0~' <br />PERMIT NUMBER: / 0 f -c-J.-o c;t-. <br /> <br /> <br />Alteration <br />i.......... /, <br /> <br />rtr~~?flSiding <br />O"Draintile <br /> <br />o Addition 0 Garage <br />o Grading (see supplement) 0 Demolition <br />Other: t="E~U? \2\::-?~"""MC:-N\ <br /> <br />A <br /> <br />OWNJm'i '. <br /> <br />Address: <br /> <br />1Se~'vL4- <br /> <br />::t Co-; - <br /> <br /> <br />- V;-::t <+=r <br /> <br />\~ <br /> <br />License Number: <br /> <br />J1, ~CI i ('I ( -r( t ^-~~ <br /> <br />C81 AiL uJo-uD r't"rJ L( <br /> <br />I <br />(" <br /> <br />WITl+ <br /> <br />INDICATE SQUARE <br />FOOTAGE OF: <br /> <br />~l\t;fl6br~ ' <br />2nd floor: /' \ \.. <br />rtf-.-. . .,:_' ., "'-' <br />3 \ fl.oor:'~: ' <br />\""-, . '. '. <br /> <br />Porch: <br />#of Stories: <br /> <br />.~ <br />Acknowledgement and Sign.atur~. . .'~' vC '" . <br />The undersIgned hereby makes apphcatlOl,I tp1:\1e CIty df~osevIlle to perform the work as herem 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 />Print Name: . \6 \2 (I r(V\~fl\FLp \"- Signature: 'R~M;o <br /> <br />o Contractor 'itiOwner o Architect Phone: ((J5i-40FqQOD . Date:~i&~i.. <br /> <br />OFFICE USE ONLY: <br /> <br />SEP ARA TE PERMITS REQUIRED: <br /> <br />FEES: <br />Permit <br />State Surcharge <br />Plan Check <br />Cert. of Occup, <br />Metro SAC <br /> <br />o Electrical <br /> <br />o Mechanical <br /> <br />o Plumbing <br /> <br />o Water 0 Sewer <br /> <br />$ ....~ <br />$~"~ <br />$ .'<. ).( X A: X <br />$ <br />$ <br />$ <br /> <br />$ <br />$ <br />$ <br />$ <br />$ <br /> <br />1 ,/ <br />j/lf7Z0 <br />/r \ <br />4. ) ,-j <br />j, <br /> <br />Water Meter (# ) <br />Constructi~n I?eposit ItS <br />Contractor s LIcense ({.f.{d-, (AK-'{''- <br />Assessments /<:Lf.-J\.. <br />Park Dedication <br />Other: <br /> <br />WARNING: Be 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 />Total Fees: $ <br />Receipt #: <br />Receipt Date: <br /> <br />-j3J~Z7113..! <br />lj / ;F) / (11 <br />