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Application for Building Permit 7800 Golden Valley Road, Golden Valley, MN 55427-4588 Phone: (763) 593-8090 Fax: (763) 593-3997 TTY: (763) 593-3968 Date _____________________ (Turn page over to complete application) Permit No._________________________ Site Address Suite # Tenant (Co.) Applicant: Owner ________ Contractor ________ Lot _______ Block _______ Addition ____________________ Property Name ______________________________________________________________________________ Owner Address_____________________________________________________________________________ City _______________________________________________________________________________ State _______Zip _____________________Phone:___________________________________________ Cell:__________________________E-Mail _______________________________________________ Contractor Company ____________________________________________________________________________ Address __________________________________________ City _______________________________ State __________Zip ______________________ Phone:_______________________________________ Fax: __________________________E-mail ________________________________________________ Contact Person ______________________________________ Cell: _____________________________ Contractor License # ______________________________ Expiration Date _________________________ EPA Lead Certification # ___________________________ Expiration Date _________________________ Designer/ Company ______________________________________________ Phone:________________________ Architect Address ___________________________________________City ______________________________ State ____ Zip___________ Contact _______________________________Cell:___________________ Fax:___________________________E-mail ________________________________________________ Zoning:  01 - Residential  02 - Commercial Bldg Permit Type:  70 - Main Structure  74 - Bsmt. Finish  75 - Chimney/Firepl.  77 - Interior Demo # Windows _________  04 - Garage b. Pocket unit/sashes___  05 - Demolition # Doors_________  07- Pool  73 - Fire Damage  10 - Moving  78 - Bridge  13 - Gazebo  27 - Tower  24 - Front Steps  19 - Drain Tile  14 - Other Structure  15 - Reside  80 – New  81 - Remodel/Alt  88 - Replace  99 - Undefined  71 - Tenant Space  72 - Window/Door Work Type:  03 - Institutional  82 - Addition  83 - Repair  20 - Shed  22 - Stucco Finish Soffit___ Fascia____Tr__  23 - Stucco Redash  16 - Reroof/Tear-Off  25 - Reroof/Flat Roof House_____Garage_____  26 - Retaining Wall  17 - Deck  27 - Insulation  18 - Porch/3 Season  13 - Elevator  21 - Front Porch  99 - Other _________  28 - Handicap Ramp __________________ Description of Work________________________________________________________________________ __________________________________________________________________________________________ Description of Use of Space__________________________________________________________________ _________________________________________________________________________________________ Office Use Census Code: Office Use SAC Code Office Use Required Inspections  434 - Alt./Add/ Res.  437 - Alt./Add. Nonres.  438 - Alt./Add. Res. Gar.  645 - Demo 1-Fam.  646 - Demo 2-Fam.  647 - Demo 3&4 Fam.  648 - Demo 5 or more  649 - Demo Other  30 – Commercial/Institution  40 – Industrial  50 – Demolition New  101 - 1 Fam. Res.  102 - 1 Fam. Attached  103 - 2 Fam. (Duplex)  104 - 3&4 Family  105 - 5 or more Family  213 - Hotel/Motel  214 - Other Shelter  01 – Single Family  02 – Duplex  03 – Townhouses/Condo’s New  318 - Amusement/Rec.  319 - Place of Worship  320 - Industrial  321 - Non Res. Garage  322 - Service Station  323 - Hosp./Institution  324 - Office/Bank  10 - Apartments Public Housing (20 - 23)  20 - Single Family New  325 – Utilities  326 - Schools/Ed.  327 - Retail/Rest.  328 - Other Nonres.  329 - Nonbldg  02 - Final  08 - Soil Test (Req’d Before Footing)  03 - Footing  04 - Framing  05 - Radon  06 - Insulation  07 - Ice & Water  09 - FlatRoof/Tearoff  10 - Wall Reinforcing (C.M.U.Inspect at 4’ lifts)  14 - Drain Tile  16 - Poured Wall  17 - Fire Stopping  18 - Floor Slab  19 - Lath  21 – Duplexes  22 – Townhouses  23 – Apartments  11 - I & I 23 - Sanitarian Final  26 - Special Inspections  90 - Other  98 - No Ins Req’d Permit and Plan Review Fee are based on 2004 LMC/AMM Recommendation. Estimated Value of Work $ _______________________ Description Office Use Only Square Footage Basement 1st Floor 2nd Floor Sq.Ft. per Fl Above 2nd Total Square Feet Garage-Attached Garage-Detached Length _______ Width _______ Bldg Permit Fee Plan/Site Check Fee State Surcharge Fee (Value X .0005) S.A.C. Fee Other $ ________________ $ ________________ Total Fees $ ________________ Stories _______ Occupancy Type _________ $ ________________ $ ________________ $ ________________ Construction Type __________ The undersigned hereby represents upon all of the penalties of the law, for the purpose of including the City of Golden Valley to take the action herein requested, that all statements are true, and that all work herein will be done in accordance with the ordinances of the City of Golden Valley and the State of Minnesota. __________________________________________________________________ ____________________ Applicant’s Signature Date This permit shall be null and void if work is not started within 180 days or if work is suspended or abandoned for 180 days.  Permit Approved By:  Stormwater Management Permit Required Stormwater Mgmt. Permit #______________ Date Issued_____________________________ Date Inspected__________________________ Stormwater Mgmt. Permit Not Required ___________________________________ ___________ _______________________________ _________ Signature I:Build\PermitApplication (01/01/2013) Date Signature Date