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Its c-7 <br /> MinnesoConstruction tDepartment Cd s nd Lice sing Div s Division e2oo 9 <br /> Building Plan Review/Inspections MINNESOTA IDEPARTMENT O <br /> 443 Lafayette Road North LABOR & INDUSTRY <br /> St.Paul, MN 55155-4341Ask <br /> Phone: (651)284-5068 Fax: (651)284-5749 <br /> www.doli.state.mn.us/buildingcodes Application for Plan Review <br /> TTY: (651)297-4198 <br /> PRINT IN INK or TYPE your responses. <br /> PROJECT TITLE Yr-d� n�2�-v►�ed1,��e �n�y��l �y,�e�I-z!�„y SGS ory15 PROJECT <br /> ED CONSTRUCTION VALUATION <br /> -1 <br /> Sz- .JJ ✓'i Off^ ✓� G'X�Pr✓-, In lam,ei� �)()�.s 1 , ?'- 000 <br /> ADDRESSANTICIPATED START DATE n]� <br /> (o�S-olA Gays +l &A,/ )2� N. 1�gs QIP cYsJAi 6AY rte.N NIA q i�q <br /> Ma1A'^7 <br /> CITY OR TOWNSHIP WHERE LOCATED***PLEASE VERIFY— COUNTY STATE PROJECT ND.- <br /> - <br /> Akxv- s-a L-ony LAlc.e. ���-i�ny , �,+y D9- oronv 4enneyo,".1 <br /> s <br /> OWNER(OR STATE AGENCY IF APPLICABLE) CONTACT r�r�ovry <br /> Groh o �°I�I�I.G SG►�ool5 — _r"5P4'"279, o� -i <br /> ADDRESS PHONE <br /> qg�2 <br /> CITY STATE ZIP CODE FAX <br /> L OM6 Lake M N 55")0 q'SZ <br /> DESIGN FIRM PROJECT CONTACT <br /> Vv yr�1� -�TGCS ahv� i rFZ C 1l <br /> ADDRESS I __ PHONE <br /> 30 �'� pe. r ��*�&°�' &F-I 227- 7773 <br /> CITY STATE ZIP CODE FAX <br /> S4-_ PAi,1 N N 5' 710.2_ 6,9-1 223 <br /> E-MAIL <br /> Check if you would also like to receive your plan review by e-mail Na <br /> B 0ldq-e•con, <br /> PROJECT TYPE <br /> ❑ Public(state-owned)building paid for by the state or other state agency for. <br /> ❑ National Guard ❑ Historical Society ❑ MN Zoo ❑ D.O.T. ❑ D.N.R. ❑ Iron Range R <br /> ❑ MNSCU(State College or University) ❑ State Hospital ❑ State Home ❑ Capitol Complex <br /> Public school district building of$100,000 or more in construction cost <br /> ❑ State Licensed Facility licensed as a: <br /> ❑ Hospital ❑ Nursing Home ❑ Correctional Facility <br /> ❑ Supervised Living Facility ❑ Free-standing Outpatient Surgical Center <br /> CLASS OF WORK <br /> ❑ New Building Construction ❑ Addition X Remodeling ❑ Other,specify <br /> IBC OCCUPANCY CLASS IFICATIONS) TYPE OF CONSTRUCTION I SPRINKLERED <br /> IBC <br /> A� � �t 3 A Yes ❑ No ❑ Partial <br /> PROJECT DESCRIPTION McCLtq,,-"j a,.l ��G-}�.; U1'�j�"G+�2S � A-t7A- 'A",ftAej , GSA GSJac7Aa-e�l <br /> c.0��+' 1'>✓I���ar+'S , o(ed-err,c� r,of�����•►n ce. ��w,s a}- 1ZS,6(D 5�. ��1c�r,.e,l.�.►.�53(o i D S,�. <br /> NOTE: The following materials must be submitted(as applicable),with this Application for Plan Review: <br /> 1. Complete set of Plans and Specifications 4. Code Record 7. Soils Investigation Report <br /> 2. Addenda and/or Change Orders 5. Sample Structural Calculations 8. Energy Code Envelope <br /> 3. Plan Review Fee 6. Special Inspection Program Compliance Forms <br /> Licensed professional: /attest that these plans and/or specifications were prepared by me or under my direct Minnesota Registration No. <br /> supervision and that reasonable care has been given to compliance with applicable laws, ordinances and building 1-7 q 3' <br /> codes and that this application is not a building ermit nor does It authorize the star`of construction <br /> APPLICANT NAME( RINT) APPLICAN IGNATUR DATE <br /> C7le'r A. I--�I►l0 (� /o ee' <br /> Is this project on the State"MAPS"accounting system? ❑Yes [g No State Agency that will be paying fee? <br /> Calculated Plan Review Fee(ByA licant FOR OFFICE USE ONLY <br /> A plan review fee must be submitted.Please see Plan Review Fee Project N Date Amount of Check <br /> the Plan Fee Schedule Worksheet for correct 2 v 10 Ov-5 V 110-47-09 '/�1 ® 9� <br /> calculation of the required Ian review fee l270, 5-� Q( v ®'�/ <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(DIAL-DLI)Voice or <br /> TDD(651)297-4198. <br /> BCS 02(2/07) <br />