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Buzlding
Inspcctions
7G3-572-3604
"7�3-502-49?'� F�1X
SITE ADDRESS _(,�,(
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SUBMtT A COPY t7F
YC7UR STATE LICCNS�
AND CERTIFIGATE �F
1NSl,JRtIN��
PRpPERTY TYPE
From: HomeSure Page: 2/5 [7ate: 11/18/2Q11 1:26:59 PM
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EFFECTIVE 1-1•201 �
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❑ OWNETt OCONTRACTOR
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STATE
❑ SINGLG FAMILYi1+1i
CI TWO FAMtLY/NEVJ
� BASEMEN7 PiNISF[ O RPG1F
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STORiES
TYPE QF WORK: � D NEW IiOME COH5TRUCTION � ADDtTtON
O MAiNTGNANCG/ftEYAIR �1 REMODEI,ENG
DESCRIDE WORK DEING DG1NG, � ,�+�������,�c
31'LE aF dMp[tOVEMCN7 LENGThI W]p'r�•j
R�� 0 I•lQiJ$� UN1.Y
NUtv[p�R, OF SQUARES � 1•IOU5E d� �ARAGE
,A A . .5
PROPOSED �IZE;
?ROM7^�Eb 1•IEICI�tTt
S1nINC
Q Vinyl
4 Alumi»um
a o��,�►
Wll�if} ��17WR
1N EXISTIN�, OPENINGS e:� C1Nu
OR FdR NEW OPENINGS=dCSCtLIQG SIZE OF
OFGNING Cl•fANGES &
�AC.,ras
Pian �.cview
Firc Sur�tu�rge
Surchurgc
Liccasc Surcbar�c
SAC Chsr�c
Curb Cut �scrow
�rosian Coatrvl
Park Fcc
C7 ATTACI iGA CAftAGG
O DE'FACI•lE6CARAG�
os��r,r
O Trim
a Fnxcio
44GATION Of W1Np0WS
�NG T1iE ]997 U.B.0 TE� SCHEDULG)
ATE�j�:IP,
TlLE
T�ACEIN•.N7'R �,rnnc�.iu�.ti�1��.r�r,
1. �acirslin� Plppr Pl:ul
a rcancryca noo� �lon
3, f�i,rt of,�tn�cturul �n�mbcr� ta hc ufiaJ
FOR NEW CQf�STRUCTtpN lNCi.VDi1+iC DCCKS,
ADDITfON5. k PORCi_IFS S�rr�n�[aT;
1� Si�c Ptun/Survcy sltowing [hc Gxirtin�j ytrµpCUrC�
nnd pr��owC(1 prqjCCt,
3 Two xetx ol' conytructipn plana
3, �nert;y Cuiculs��ivny
FOR WJNI}�w5 — TROVIDE U•VALUE AT�D
MANUFAGTURE STICKCR ON WINDQW.
OGCUnANCY TYPE
S�c Back Pagc foe l�cc Schcciulc
65%� of B�ilding f+crmil Fcc
.OU1 titnes th� tol�l job valuatipn
.0005 x Pcrmit Vatuulion Minimum $5,00
$5.00 (Stzttc Liccnscd Rcsictcn�i�►I �un�rtic��r,)
�2230 �scr SAC Unit {Pl:ms w MWCC for ciclenttinution)
R+6ft=.�. _ iix�?5=�
545U ConsGrvation Plun Revicw
Fao Dctcrmincd t�y Enginccrinb
Scwer Ma,n Ch�rgc � Agrccmcn� ncccs,r-sry O Non Ncccssary O
Tot�i Duc $ G� �j Mnkc chccks nuvublc #a: Citv oP �'r[dlcv Attnch Stiputatiana;
TIi[5 !S AN AhYLICA710N Ft�R A P�RMtT.Nc)'1' VA4FD UNTfi� eRa['�S5EI1
I horG�iy apply for a buil�iin� n�rmit an�i I ackriowlcdgc th�t thc infortnation ab�ve is eonsplcte und ac�uratc; that thc wvrk will bc in
canfvrtnancc witlt tt�c drdinunccs and codcs of thc City of 3�iritllcy anc! with thc Minncsot� Con�truction Codcs; that I undcr�u�nd this is not a
permit but only fln appl;cation for a pernti[ nn�1 work iti nat tv st�rt without a�crmit on sitc; tlsat thc work wili bt in accord��ac with thc
approv�d pl;�n in thc cunc . li w wlric � ixqu'res rcvicw an�l npprovnl of p ns. �/
SlGNATURC 0� APPLICANT ,,, PR1NT' NAME.�d.0 �;_Lr'1,�i es DATG�,,,�,�
APPRL}VAL IIJS!'�C'fOft SIGN L1ttN, _ �'�'