2009-00140ADDRESS
PIN
LEGAL DESC
PERMIT TYPE
PROPERTY TYPE
CONSTRUCTION TYPE
VALUATION
NOTE: 26 SQUARES OF SIDING
CITY OF MONTICELLO
505 WALNUT STREET
MONTICELLO, MN 55362-
763) 295-3U6U VAN: (763) 295-44U4
6318 86TH ST NE
155186001080
CARLISLE VILLAGE 3RD ADDN
LOT 008 BLOCK 001
BUILDING
SINGLE FAMILY -DETACHED
SIDING
7,800.00
HOMEOWNER AFFIDAVIT REQUIRED TO BE TURNED IN PRIOR TO START OF WORK
APPLICANT
CLARK, JAMES
6318 86TH ST NE
MONTICELLO, MN 55362-
OWNER
CLARK, JAMES
6318 86TH ST N E
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 9- 0 0 1 4 0
DATE ISSUED: 02/18/2009
BUILDING PERMIT FEE
STATE SURCHARGE, BLDG VAL
TOTAL
Payment(s)
CHECK 2165
162.45
3.90
166.35
166.35
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
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MONTICELLO
DEVELOPMENT SERVICES
BUILDING INSPECTIONS
505 WALNUT STREET, SUITE I
MONTICELLO, MN 55362
City Hall (763) 295-2711
PERMIT #
PID #
Building Inspections (763) 295-3060 Fax (763) 295-4404
Please Print - INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED.
SITE ADDRESS: (` ( * S' } rvz. / . F . ZONED-
LEGAL: Lot Block Plat
Property Owner Name: ... '-t < Phone: Cam% l Z 1 7 / G
Cit . e z State: Zip: ( 34-
Address: i Y `KC, S _- fi i U : ta. y ..+ „-i(c
Contractor Name:
Phone:
State License 4:
Address: City:
Eng./Architect Name:
Phone:
Address: City:
Phone:
Plumber Name:
Address: City:
Phone:
Mechanical Name:
Address: City:
Tvne of Work
New
Addition
Alteration
a Repair
Move
Other
Description of work:
r ,- -
State: Zip:
State: Zip:
State: Zip:
State: Zip:
y
Type of Construction Building Information
Single Family Use of building 'H. e-S
Duplex: of stories Z
Multi -Family Floor area sq. ft.
Commercial Estimated value
Industrial of construction
Residential Garage Is this a "Master Plan" per MN Rule
El Other 1300.0160 Subp.6.. Yes No
OR ROOF & SIDING PERMITS
EASE PROVIDE # OF
QUAKES OF SHINGLES &/OR
SIDING
1 hereby apply for a permit for construction as described and acknowledce that the information I have provided above is complete and accurate. Iagreethatthewort: will be conducted in conformance with the ordinances of the City of Monticello and with the Laws of the State of Minnesota; and that I understand that this application is not a permit and that the wort: is not to start without a permit. 1 further understand that the work willbeinaccordancewiththeplanthathasbeenapprovedbytheBuildingOfficial. 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.
A lica tbn re
SEE BACK FOR PLUMBING
Z i-7 I ° `j AND MECHANICAL INFO.
Application Date
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BUILDING PERMIT APPLICANT: PROPER1 Y v ' 1Ir`
I understand that the State of Minnesota requires that all residential building contractors, qualify for a specific exemption
remodelers and roofers obtain a state license this document, I attest to the fact that I am
from the licensing requirements. By gm g t from the state
building or improving this house myself. I hereby claim to be exempt
property
licensing requirements because I am
for purposes
not building or improving P P
f speculation or resale and that the house for which I am aPPlYing for this permit, o
e
p _ _ y is the first residential structure I have built
located at V"7 ° ¢i
roved in the past 24 months. I also acknowledge thaottbherwise have beenaententitled
state
or imp is to which I May
license, I forfeit any mentechanic's lien righ
at I do construct or rove another residential
under Minn. Stat. §514.01. In the Bill not dodo so until I obtain the required state license, structure in the next 24 months, I wunderstandingthatfailuretodosois 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 a house
State
u
Minnesota
that
I
sortP some
of these contractors may be required to be license Yand/or roofing activity is a understand
that unlicensed residential contracting, remodeling, so
acknowledge that all licensed misdemeanor
under Minn. Stat. §3 tor'
s'26.
92, Recovery
I.
Fund,
which can pay homeowners contractors
pay into the Contractor s Recovery complete work or up
to $50,000 in the event their licensed contra i tractortosreimbuto sement
from
the performs defective
work, but that I forfeit my g Cont ractor'
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 secuted P
ro
and that I can be p connection with
the work performed on this p p5', by the CitY criminally for
any code violations that are not corrected as ordered f ignature
of
Prop rty Owner z r
Date wired
to
be licensed, or to check To determine
whether a particular contractor is required se call
the Minnesota on the
licensing status of individual contractors, p the Minnesota
or toll
free of
Commerce,
Market Assurance Division, at ( ) free at
1-800-657-3602.