P - 41735From: 715 684 3859 Page: 1l1 Date: 10/3l2011 11:23:06 AM
BuiIdin.g
Inspections
7fi3-S72-3C�4
763-542-4977 FAX
DATE " -
STTFs ADDRESS
THIS APPLICATTT IS: ❑
�UILDIr1G
RESIDENTIAL APPLICATI{�N
CITY OF FRIDI.IEY
PROPERTY OWNER! I NAME: � �.
TENANT ADDRGSS; _ "'
CONTRACTOR
su$MiT n carx o�
YOUR S'TATE LICCNSE
AND CERTIFICATE OF
iNSUCLANCE
PROPERTY TYPE
PERMIT TYPE
OF WORK:
AESCRIBE WORK BEIN(}
NAn��: c_.F r cL
S7'A'CE LTCENSF, #
[ONE�I�S "���� Y""" �''��
SINGLE FAMILYlNEW CONSTRUCTION
'CWO FAMCiY/NEW CpNSTRUCT[ON
❑ BASEM�NT FINCSH
❑ D�CK
HOME CONSTRUCTION
BO�FAVG (
NUMBER OF' SQUARGS j�
CrAIir1,GES
PRaPOSED SiZE:
PRONOSED HEIGHT:
SI�ING
O Vinyl
❑ Aluminum
D Otfier
�'S'�JRSL
TN EXISTING OPENINGS ClYes C1No
OR FOR NEW �PENSNGS-DESCRCBE ST'/.E OP
OPENING CHANQ}iS &
C7 SCDING
Q SWIMM
Pernait No.a�b
Received By�
Date Rec'
� �CI'1`Y_�� ,,,�SI'A'
LEAD CERT NUMBER '
�� CITX �
FAX
SIZE
STORIES
JSHED C71�7'NDOWS
O DRAIN TILE
❑ OTHER
NG POOL
❑ AADITION
C7 REMODELING
O QtISE ONLY
�HOUSE 8c QAiLAQE
C] A'P'CACH�ll GARAG�
CI DBTACHEP GARAGE
OSofflt
❑ Trim
� Fascia
LOCATION OF WTNDOWS
B{�SEMENT REMQpET.TNG SUBMIT:
l. Existing i�loor Ptan
2. Proposed floor plan
3. List of structurnl irambers to be used
FOR NEW CONSTRUCTION RJCLUDINO DECKS,
AUDI'fISJII� 8c PORC'H ._ F�MIT:
]. 5ite Plan/Survey showing the existing slructures
and proposed project.
2, Two sets of conswction plazu
3, Energy Catcutadons
FOR W'MDQWS - PEtOVIDE U•VALUE AND
MANUPACTi1HESTICKGRON WINDOW.
TYPE OF WINDOW TO BQ INSTALLED NUMHER OF WINDOWS I
^ ALL FEES ARE BASED ON VA,Y.�UA'Y'ION, INCL[FDING THE GOST OF LABOR AND MAT�RIALS:
US�G THE 19�7 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION $ Q�• OCCUPANCY TYPE
Permit Fee $ See �ack Fage far Fee Schedule
Ptan Review $ 65% ofi Building Permit Pee
Fire Surcherge $ ��,}- .001 times the total job vatuation
Surcharge $ .0005 x Permit VaEuation Minimum $5.00
License Surcharge $ ji�� $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to M'WCC for determination)
Curb Cut Escrow $ ft+ b ft= ft x$25= $
Brosion Control $ $4S0 Cvnservation Plan Review
Park Fee $ Fee Determined by �ngineering
Sewer Main Charge $ Agreement necessary (} Non Necessary ()
Total Due $ s;7 ,(C 3 _ Make checks paYAble tv: City oi Fridiey Attaci
TfiIS IS AN APPLICATIRN FpR A PEftMI'C-NOT VALiD UNTIL PROCESSBD
I hereby app[y for a building permit and I acknowledge that the inforrnation above is complete and accurate; that the work wiEl be in
conformanee with the ordinanc and codes of the City of �'ridley and with the Minnesota Construction Codes; that 1 understand this is not a
perznit but only an applicatio fo a permit w rk is not to rt without a rmit on s' e; that t�e work will be In accordance with the
roved Isn in the case of I wo whic r ' e r�ew an rov of 1 %� /�
�'p p 1` 1 K
SIG�NATURE OF APPLICANT PKIN�'�AMEp DATE %�,�/i