2008-01698CITY OF MONTICELLO
505 WALNUT STREET
MONTICELLO, MN 55362-
763) 295-3060 N'AX: (763) 295-4404
ADDRESS 6305 86TH ST NE
PIN 155186001020
LEGAL DESC CARLISLE VILLAGE 3RD ADDN
LOT 002 BLOCK 001
PERMIT TYPE BUILDING
PROPERTY TYPE SINGLE FAMILY -DETACHED
CONSTRUCTION TYPE ROOFING & SIDING
VALUATION S 11,600.00
NOTE: FINAL INSPECTION TO BE CALLED IN A MAXIMUM OF 48 HOURS AFTER COMPLETION
APPLICANT
HILLSTROM, DERRICK
6305 86TH ST NE
MONTICELLO, MN 55362-
OWNER
HILLSTROM, DERRICK
6305 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. 1 agree that any damage caused to
public property including but not limited to curb sidewalk,
public utilities and signs will be repaired at my expense
Applicant
Date
Bldg Official Date
2 0 0 8- 0 1 6 9 8
DATE ISSUED: 07/31/2008
BUILDING PERMIT FEE
STATE SURCHARGE, BLDG VAL
TOTAL
Payment(s)
CHECK CC
221.81
5.80
227.61
227.61
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
MONTICELLO
DEVELOPMENT SERVICES PERMIT P
BUILDING INSPECTIONS P t t'
505 WALNUT STREET, SUITE I
MONTICELLO, MN 55362
City Hall (763) `_'95-?7l l Building Inspections (763) ?95-3060 Fax (763) ?95-4404
BUILDING PERMIT APPLICATION
lease Print - INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED.
SITE ADDRESS: ZONED
LEGAL: Lot Block Plat
Property Owner Name: vs,`c ( 5 6 c, m Phone:
Address: E 5c — f S. %I City: {Il,-<< State:^\ Zip:
Contractor Name: Phone:
State License'':
Address: Cite: State: Zip:
Eng./Architect Name: Phone: _
Address: City: State: Zip:
Plumber Name: Phone:
Address: City: State-._______ Zip:
Mechanical Name: Phone:
Address: City: State: Zip:
Tune of work Tyne of Construction Building, Information
New 1K Single Family Lise of building '
Addition DupleX r of stories
Alteration Multi -Family Floor area sq. ft.
Repair Commercial Estimated value
Move Industrial of construction
Other Residential Garage Is this a "Master Plan" per MN Rule
Other 1300.016o Snbp.6.? Yes No
Description of work: FOR ROOF & SIDING PERMITS
6 PLEASE PROVIDE # OF
7 SQUARES OF SHINGLES &/OR
SIDING
I hereby apple for a permit for construction a descrihed and acknowlcclLc that the information I have providcd Ihov e is conrhlctc and accurate. 1
aL,rec that the wort: will be conducted in contorrloancc ith the ordinances ofthe Cite of Monticello and v ith the Laws of the State of %l inne ota_
and that I understand that this application i; not a permit and that the wort: is not to start without a permit. 1 further understand that the \,orl: Mil
be in accordance with the plan that has ncen approved b\ the kuildin<L Official. I agree that an% damage caused to public nroncny includine but
not limited to curb_ sidewalk, public utilities and signs Neill he repaired at mY expense.
l
Applicant Signature
7->r-
Application Date
SEE BACK FOR PLUMBING
AND ]MECHANICAL INFO.
APPLICANT: Please show fixtures that are a ymeame.
Fire Suppression : (if applicable) I Plumbing: (if applicable) Mechanical: (if applicable)
No. Fixture Type
Sprhikler Heads
Other /Special FS Device
Fire Alarm: (if applicable)
No. Fixture Type
of Devices
Other
FEES:
Bld0. Permit
Plan Revie%
State Surcharge
Bldg. Total
Plm-. Permit
Fixtures
Surchar<-,e
No. Fixture Type
Hater Closet (toilet)
Bathtuh
Lavatory (wash basin)
Shower
kitchen Sink
Dish washer
Lamidn, Tuh
Clothes Washer
0 ater Heater
UrilI tII
Drmkin- Folmtam
Floor Drain
Slop Sink
H dralits
Plmg. Total
Mech. Permit
Fixtures
Surcharac
Mech. Total
Sewer Access
Water Access
Water Meter
Meter Sales Tax
Meter Total
Sew & Water Permit
Trunk Water
Trunl: Sanitary Sewer
Trunk Storm Sewer
Lift Station
TOTAL FEES:
TOTAL
9 Per Fixture)
FOR :CITY US.E ONLY -
No. Fixture Type
Furnace
Gas Meter
Range Hood
Gas Range
Water Heater
Air Conditionhtg
Alech. Fireplace
Bathroom(s) Exhaust Fan
Air Etichauner
Drver
Gas Opening w/o Fixture
TOTAL
S9 Per Fi_sture)
Tree Ordinance Handout Yes No
Other Handouts Ves No
ADDITIONAL INFORMATION:
Valuation:
Construction Type:
Occupancy Group:
Division:
Square Footage:
of Stories: _
of Residential Units: _
Maximum Occupancy:
Fire Sprinklers: 'o
Off -Street Parking Covered:
Off -Street Parking uncovered:
Building Official
BPT:
Efi
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 a specific exemption
from the licensing requirements. By signing this document, I attest to the fact that I am
building or improving this house myself. I hereby claim to be exempt from the state
licensing requirements because I am not building or improving this property for purposes
of speculation or resale and that the house for which I am applying for this permit,
located at (3 G) C 5> t, iis the first residential structure I have built or
improved in the past 24 months. I also acknowledge that because I do not have a state license,
I forfeit any mechanic's lien rights to which I may otherwise have been entitled under
Minn. Stat. §514.01. In the event 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. I also acknowledge that all licensed contractors
pay into the Contractor's Recovery Fund, which can pay homeowners up
to $50,000 in the event their licensed contractor fails to complete work or performs
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 any violations of the State Building Code and/or city ordinance 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 3i-
0(- Date
To
determine whether a particular contractor is required to be licensed, or to check on
the licensing status of individual contractors, please call the Minnesota Department
of Commerce, Market Assurance Division, at (651) 296-2594, or toll - free
at 1-800-657-3602.