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� Minnesqta Depa�tment of Labor and Industry <br /> Construction Codes and Licensing Division � MINNES07A DEPAR`I"MEN7 OF <br /> Plan Review/Inspections L,ABOR & 1NDtJSTRY <br /> 443 Lafayette Road North <br /> St. Paul, MN 55155-4341 � <br /> Phone: (651)284-5068 Fax: (651)284-5749 Application to the <br /> www.dli.mn.gov State Appeals Board <br /> PRINT IN INK or TYPE your responses. <br /> MUNICIPALITY <br /> BUILDING OFFICIAL PHONE E-MAIL ADDRESS <br /> MAILING ADDRESS CITY STATE ZIP CODE <br /> PROJECT BEING APPEALED <br /> Project is Has the permit been issued? <br /> ❑ One&two family building ❑ Other building type ❑ Yes❑ No <br /> APPLICANT REQUESTING APPEAL PHONE <br /> E-MAIL ADDRESS <br /> ❑ Owner ❑ Contractor ❑ Designer ❑ Attorney ❑ Other <br /> MAILING ADDRESS CITY STATE ZIP CODE <br /> CODE,YEAR AND SECTION BEING APPEALED <br /> SUBJECT <br /> BASIS: (check which of the following apply) <br /> ❑ The true intent of this code or the rules have been incorrectly interpreted; <br /> ❑ The provisions of this code do not fully apply; <br /> ❑ An equally good or better form of construction is being proposed <br /> CERTIFICATIONS <br /> Our municipality does not have an appeals board and,therefore, requests that the State Appeals Board hear this appeal.A copv of our final <br /> determination on the matter is attached. <br /> SIGNATURE BUILDING OFFICIAL CERTIFICATION NO. DATE <br /> I hereby certify that the above information is true and correct. <br /> SIGNATURE APPLICANT LICENSE#(if applicable) DATE <br /> This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 <br /> (DIAL-DLI)Voice or TDD(651)297-4198. <br /> BCS 11 (2/07) <br />