Site Information
Site Address:
Owner Name:
Owner Telephone #:
Property ID (new construction only):
Lot: Block:
State: ____ Zip:
Contractor Information:
Contact Person:
Telephone #:
Construction Type:
Type of Work / Description of Work:
_ New Construction _ Finish/Remodel
_ Sign Permit _ Septic System
_ Grading Permit _ Addition
_ Deck _ Other
_ Window/Door(s) (new cut-in)
_ Mechanical
_ Plumbing
_ Window/Door(s) Replacement
(within same opening)
Re-roof: asphalt
_ Re-roof: wood - must also submit
"Supplement for Wood Roofs Form" Submit
application for above work types to:
Valuation of Work: $
When permit is ready:
Structure Size: Length Width
Sq. Ft. Height
Permit application for above work types
must be accompanied with one full size (to
scale) and one 11”x17” size set of drawings.
Submit application to:
Full size drawings and payments may be
dropped off at City Hall.
City of Medina | Planning and Zoning Department
2052 Co Rd No 24 | Medina, MN 55340
Phone: (763) 473-8852 Email:
Acknowledgment and Signature:
The undersigned hereby requests permission to make the real improvements specified, and declares under penalty of law acknowledgment and acceptance of
all information, conditions, and requirements represented on this document. The undersigned affirms to the accuracy of all information submitted along with
the application and acknowledges responsibility to pay for plan review costs associated with this application regardless of if the permit is issued.
The undersigned recognizes that this document is merely an application and that no work may be completed until plans have been approved, all permit fees
are paid, and the permit has been issued. After the permit has been issued, the undersigned agrees to do all work in strict compliance with all City of Medina
ordinances and State of Minnesota building code requirements. The undersigned further agrees to carry out inspections necessary for this permit.
Applicants Signature Applicants Printed Name Date
DUE TO COVID-19: All building
permit applications and supporting
documents should be submitted via
email. After review, any further
instruction will be communicated
via email.
We now accept on-line credit card
payments (convenience fee applies).
Office Use Only
Permit #:
Receipt Date
Adjusted Valuation
# Mechanical
# Plumbing
# Fireplace
Code Analysis
Site Visit Fee
Other Fee(s)
Building Official Approval
Special Conditions or Comments: