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��l � <br />COMMUN7''_`Y DEVELOPMENT DEPARTMENT � PHONE: 651-49t1-2238 • FAX: 651-490-2931 <br />RESIDENTIAL B UILDING PERMIT APPLICATION <br />�ti'ORK PROPOSED: <br />❑ Ne�v <br />❑ Deck <br />❑ Window <br />���Alte�ration <br />�"r {��iy�of/Siding <br />� ❑ Draintile <br />_- - <br />APPLICATION DATE: ��2 � � �( (p � <br />�.� ' <br />SITE: .� ress; ��' Si-��'��i �3C�c�.-E-�' �V� <br />ot ( Option � 1: ,� �-�� �� B on )_ <br />�if� � <br />f1PPLIC��'T: ,�,��$--+.,,�(�A+��' ,1-��C� <br />A ess "� V l� ���1� -` ��'li{-ir' f� <br />OWt�tE� R' ,.; ''ame: �I L�`',� -�Q `�,,_.4-- � <br />:� «,5: <br />'! �� �- � N �-� �-1 �� �-�-�k- <br />CONTRACTOR: `�am� � � �� � � � � P <br />��ciress:rJ��.IJ �1l�i V�� �1�+ <br />�i, (�c:iC�o2� , <br />VALUATION (labor & materials): $ T..��j� -- _ <br />WORIC DESCRIPTION: � ��� �, x � � � � <br />UJu��� v�NUI.. <br />STRUCTURE TYPE: <br />INDICATE SQUARE <br />FOOTAGE OF: <br />0 <br />-�#;�O�r' � � <br />�� <br />2"d floor• ' � `- <br />3`•�flo.or� � � .. . � <br />0 <br />Basement: <br />Carage: <br />beck: <br />PERMIT NUMBER� �'' ���-��d— <br />❑ �ddition ❑ Garage <br />❑ Grading (see supplement) ❑ Demolition <br />�Other: ���=���'�.tc"��U�r'Uc iV��t�1T <br />, r ��i <br />��, - �-} �3 �v - I � � J <br />� �a� — �'1 S� — t, <br />� �� <br />Detached <br />� <br />� �� ` <br />, <br />� r<< � r t�� r�ti� �� ;� <br />�� �1 L�. (,� l Tl% <br />� <br />Porch: <br />#of Stories: <br />Acknowledgement and Signatur� �° �� <br />The undersigned hereby makes applicatio�e to the Citb ot�Roseville to perform the work as herein described. The undersigned further states, under penalty of <br />law, that the work rvill be performed in accordance with the Minnesota State BuIlding Code> this application, and any approved plans and/or specifications. <br />�.j,� � .'� <br />Print Name: � I� �� �� `�1 �� � � Signature: <br />❑ Contractor '4LJ Qwner ❑ Architect Phone: (�� - -���� � Date: �� <br />SEPARATE PERMITS REQUIRED: ❑ Electrical ❑ Mechanical ❑ Plumbing ❑ Water ❑ Sewer <br />FEES: �i Water Meter (# } $ <br />Permit $ � � .� -� Construction Deposit , ���� i� $�=-�-��'`��_Y <br />State Surcharge $ �� 5 C� Contractor's License (�'�-�`� �� $ %�< X' X�Y' C <br />Plan Check $ Assessments � d-�'` $ <br />Cert. of Occup. $ Pazk Dedication $ <br />Metro SAC $ Other: $ <br />WARTTlNG: Be sure to contact public utilities for location of underground cables, . Total Fees: $ <br />conduits, pipes, etc. before digging. Receipt #: / <br />Call Gopher State One: 651-454-0002 Receipt Date: � <br />��;C <br />.� <br />— <br />_ E <br />