2023-00294CITY OF MONTICELLO
505 WALNUT STREET *
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DATE ISSUED: Ih/08/2023
MONTICELLO, MN 55362-
763) 295-3060 FAX: (763) 295-4404
Permit #: 2023-00294
ADDRESS 4416 86TH ST NE
PIN 155264002080
LEGAL DESC EDMONSON RIDGE
LOT 008 BLOCK 002
PERMIT TYPE BUILDING
PROPERTY TYPE SINGLE FAMILY -DETACHED
CONSTRUCTION TYPE DECK
VALUATION 11,000.00
APPLICANT BUILDING PERMIT FEE 206.97
PLAN REVIEW 134.53
DALTON, TIM
STATE SURCHARGE, BLDG VAL 5.50
4416 86TH ST. NE
MONTICELLO, MN 55362- TOTAL 347.00
Payment(s)
CREDIT CARD 1022 347.00
OWNER
DALTON, TIM
4416 86TH ST. NE
MONTICELLO, MN 55362-
AGREEMENT AND SWORN STATEMENT
I agree that the work will be conducted in conformance with
the ordinances of the City of Monticello and with the
Minnesota State Building Code. I understand that the work
will be in accordance with the plan that has been approved by
the Building Official. I agree that any damage caused to
public property including but not limited to curb, sidewalk,
public utilities and si ns will aired at my expense.
Applicant
Date
Bldg Official Date
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
Monticello
BUILDING SAFETY
SITE ADDRESS
4114//6
LEGAL DESCRIPTION
LOT D O n
PLAT
Permit No. ZO Z3 O-Zqy
Date 3 = 3- Z 3
RESIDENTIAL BUILDING PERMIT
ADDITION / ALTERATION / REMODEL
OWNER (Name)
T,v Pal W
CONTRACTOR (Name)
BLOCK O 0 PI.D. NUMBER I, -2 6 7O 0 ?-- 0,15
Address) (Tel. No.)
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Address) (Tel. No.) f
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CONTRACTOR'S LICENSE NUMBER (IF APPLICABLE)
PLUMBING BEING COMPLETED BY (PLEASE CHECK ONE):
HOMEOWNER CONTRACTOR
IF APPLICABLE, SPECIFY CONTRACTOR Lic #
CHECK ALL THAT APPLY: TOILET SINK BAR SINK BATHTUB/SHOWER
LAUNDRY TUB SOFTENER OTHER
TOTAL # OF FIXTURES
REMINDER: IF YOU DO NOT OWN THIS PROPERTY OR ARE NOT PERFORMING THE WORK, PERMIT MUST BE PULLED
B Y A MASTER PLUMBER.)
MECHANICAL BEING COMPLETED BY (PLEASE CHECK ONE):
HOMEOWNER CONTRACTOR
IF APPLICABLE, SPECIFY CONTRACTOR
CHECK ALL THAT APPLY: FURNACE A/C FIREPLACE BATHFAN
TOTAL # OF FIXTURES Bond #
DESCRIPTION OF WORK:
1,e C
ESTIMATED VALUE OF CONSTRUCTION Approved by Building Official: .
j/ A
Date Approved:
Applicant Si ature / PP gn
505 Walnut Street, Suite 41 Monticello, MN 55362
p
Date
Phone: 763-295-3060 Fax: 763-2954404 3 y q 2 Oc)
F-- ----
BUILDING PERMIT APPLICANT: PROPERTY OWNER
I understand that the State of Minnesota requires that all residential building contractors,
remodelers and roofers obtain a state license unless they qualify for specific exemption from
the licensing requirements. By signing this document, I attest to the fact that I am building or
improving the house myself. I hereby claim to be exempt from the state licensing requirements
because I am not building or improving property for the purpose of speculation or res le and
that the house which I am applying for this permit located at:
is the first residential structure that I have built or improved in the last 24 months. I also
acknowledge that because I do not have a state contractor's license, I forfeit any mechanic's
lien rights to which I may otherwise have been entitled under Minn. Stat. 514.01. In the even
that I do construct or improve another residential structure in the next 24 months, I will not do
so until I obtain the required state license understanding that failure to do so is a misdemeanor
under state law.
Furthermore, I acknowledge that I may be hiring independent contractors to perform certain
aspects of the construction or improvement of this house and I understand that some of these
contractors may be required to be licensed by the State of Minnesota. I understand that
unlicensed residential contracting, remodeling, and / or roofing activity is a misdemeanor under
Minn Stat. 326.92, subd. 1. 1 also acknowledge that all licensed contractor's pay into the
Contractor's Recovery Fund, which can pay homeowners up to $50,000 in the event that their
licensed contractor fails to complete work or preforms defective work, but that I forfeit my
rights to reimbursement from the Contractor's Recovery Fund in the event that any
contractors I hire are unlicensed.
I also acknowledge that as the contractor on this project, I am solely and personally responsible
for and violations of the State Building Code and / or City Code in connection with the work
performed on this property, and that I can be prosecuted criminally for any code violations
that are not corrected as ordered by the City.
Signature of Property Owner Date
To determine whether a particular contractor is required to be licensed, please call the
Department of Labor and Industry @ 651-284-5012