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� <br /> , ' ► <br /> 2415 Wilshire Blvd BUILDING PERMIT <br /> , Mound, MN 55364 <br /> Phone 952-472-0607 ❑ Handout Given <br /> �� Fax 952-472-0602 ❑ Lead Handout Given <br /> �j .-�, <br /> SITE ADDRESS: � � '"i '"'� PID: <br /> 1)Was the home constructed before 1978?(YES o, continue with line 2, NO ❑ continue without completing EPA Section) <br /> 2)Will the work disturb>_6 sq ft of interior painted surfaces or�20 sq ft of exterior painted surfaces?(YES o go to line 4, NO o line 3) <br /> 3)Are there any windows being replaced?(YES❑, go to line 4, NO❑continue without completing EPA Section) <br /> • 4) Has this home been Certified Lead Free?(YES❑, you MUST Attach Certification Information, NO❑complete line 5) <br /> 5) EPA Contractor Certification Number: NAT- <br /> PROPERTY OWNER: �""x"` � ' Address: � r ''' �_� <br /> . <br /> City: State: Zip: Email: <br /> „ Contact Name: Phone: <br /> r , <br /> . CONTRACTOR: ; P a'�`+ • = Address: ' ` <br /> Cit : State: Zip: � Phone: Fax: <br /> Contractor License No: N� Contact Name: Phone: a `'i� <br /> Email: ' ,-> '�' ^ � �, <br /> ARCHITECT: � g Address: <br /> Cit : State: Zip: Phone: Fax: <br /> Email: Contact Name: Phone: <br /> ' TYPE OF WORK: ❑New Construction ❑ Deck ❑ Re-Roof <br /> ❑ Commercial ❑ Residential o Change of Use ❑ Pool ❑ Re-Side <br /> EST.VALUATION OF WORK ❑ Finish Basement ❑ Retaining Wall ❑Fence <br /> $ ' Remodel ❑ Porch ❑Shed <br /> Square feet: ❑Addition ❑ Demolition ❑Window/Door Replacement <br /> ❑Garage-Attached/Detach ❑ Misc Other #being replaced <br /> Detailed Description of Work: ❑Accesso Structure <br /> , :.; � , <br /> . <br /> Signature of this application by the legal property owner or a licensed contractor,as the owners representative,is required and authorizes the Zoning Administralor or designee and the Building <br /> Off�aal or designee to enter upon the property to perform needed inspections.Entry may be without prior notice.I hereby acknowledge that I have read this application and state that all <br /> information is true and correct to the best o(my knowledge.I further agree that all work pertormed will be in accordance with approved plans,specifications and conditions and to abide by all <br /> � ord�nances of the Municipality and the laws of the State of Minnesota regarding actions taken pursuant to this permit.I agree to pay all plan review fees even if I choose not to proceed with <br /> the work.Permit expires when work is not conwepced within 18D days from date of permit,or if work is suspended,abandoned,or not inspected for 180 days.Work beyond the scope of this <br /> ennit,or work without a ermit or ins ection will be sub ect to a enalt . <br /> SIGNATURE OF APPLICA T: DATE: <br /> PRINTED NAME: This is the signature of: ❑ Owner or ❑ Owner's Representative <br /> OCCUP.TYPE: CONST.TYPE: CODE: BLDG SPRINKLED Yes/No <br /> VALUATION: $ COPIED APPROVED <br /> Permit Fee: $ <br /> Plan Review Fee: $ ZONING <br /> } State Surcharge: $ CITY ENG/DPW <br /> � Site Inspection Fee: $ PUBLIC WORKS <br /> z <br /> O S.E.C. Fee: $ UTIL TAX OTHER <br /> y Investigation fee/Other Fee: $ ASSESSING/UTIL BILL <br /> W Copy Charge($.25 per 8.5 x11 page) $ BUILDING OFFICAL <br /> v License Check($5)/Lead Check($5) $ <br /> LL <br /> 0 Sub Total $ <br /> Special Conditions/Required Setbacks: <br /> Building Approval By: DATE: <br /> Printed Building Approval By: ❑ License Verification ❑ Lead Verification-Checked By: <br /> City Approval By: DATE: <br /> Information supplied on this form will be considered public according to the MN Government Data Practices Act. <br /> See reverse side for an important statement regarding Indian Mounds. <br />