P - 42105Building
Inspections
763-572-3604
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51T� ADDRfiSS _ �'
THIS AP�'LtCaNT iS;
pROPERTY OWNER/
TENANT
SUBMIT A COl'Y OP
YOUR 3TATE LICL•'1�1SE
AND CERTJTTCATE ON
INSURANC�
WORK:
DESCR[BE WORK 9E[NG
From: unknown Page: 2/2 Date: 5/13/2011 8:53:01 AM
B�T��,DING
�ESIDENTI�L AP�LICA'�'�QN
CITY �F FR��ILEY
YOL'R E-. AIL ADDftESS �1 �
'�'.'C�l�Q,1% i'n*v �5�
� OWNGIt
5�3�- 7
? -'s'1 I • '-i.Sr
STaTR �,IC6NSE
�ONE -/ �1..4 .,ri 3 �' j `�i �
�INGLE PAMILYlNBW CONSTRUCT[pN
TWO FAMItY/N,BW CONSTRUCfiQN
❑ BAS�MENT FNiSIi
❑ D�CK
❑ NSw H4ME CONS'fRUC
�"fV1A TN7'BNANCEJ[i�PA [R
NU� F SQUARES �� ' ��
ItAG ..
PROPCri3ED SI2E:
P1tOPO5ED HRTGHT;
�
O Viny�
❑ Aiuminum
O Othcr
n •c
lN EXISTWC OPENINGS OYos ONu
pR FOR NEW OPENtN�S-DESCRiHG Sl'!,E pF
pPF,NIN(i CIIANGES &
ALL
Pcrmit Fee
Plat1 Review
Fire $urohAtge
Surchar�e
�.icensc Surchar�e
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
ARE BASED OlV V
g1DING
❑ ApA[TION
t7 RF,MODELING
❑ HqUSE aNLY
O HOUSE Bc CAIiACiE
O AT7'ACF��D C,ARAGE
O AETACH�,D GARAGE
1'ermit No, ;
Received 8y;
D����►1I
� . T i�t
o�
___�r"� j� (t �l STA'1'E �� ZIP -�S t-!3
C+'-7,7' NUhiBER �
CITY v1 ` SihTE fyiVZlp .�- S��
x ����-�r� -��
,IES
O tYINpOWS
O llRA1N TILE
❑ UTHAR
B�EMENTREMODE [N .S[IA��
1 Exisring Ploor P1an
2, Ptoponed fl oo� plan
3. Lisl otstr�tural mem6aB to ho used
FORNEW CqNSTRUCfiON INCL[lDiNa DfiCK3,
OSoffit nn�iT'fOlvS. � POR NRR Ci r M��
D Trim I. Site Plan/Survey showing [hc cxisStflg structrues
� FasC1a and propascd projaCC.
2, Tu�o sees of congruc[ion pluru
3. Lnerp� Calculauoes
�,4CATION OF WINDOW3 FOR WINDQWS — PttOV[Dfi U-VALUC AND
MnNUFACNRE 577CKER pN wINDOW
N �MBLR OF W WDpWS
,LUATION, INCLUDING T1�E CpST O�� I.nROR AND MATERL4i.S:
a111TG THE 1997 U.B.0 FEE SC�IEDULE)
� "1 �• 6 S 5ee Back Page for �ee Scltcdule
� 65% of Bui(din� Pcrmit Fee
$ • ,OOI rirnes the tota] job valu�tion
$ .Q005 x Pbrmit ValuAtion 112inimum $5.00
s $5.00 (Statie Licensed Resident;al Contraewrs)
$ _ �2230 per SAC l3»it (Pl�ns to MWCG for determination)
� ft�dit= f�x$25=�
$ $450 Ccroscrvation P18n Rcviow �—
$ _ �ee Detcrmined by Enginecring
g Agreem�qt necessary () 1\Tpn Necsssary ()
� D•A� Make checks nAyabte to: City of Fridlev attac
7'IIIS [S AN ,4PpLtGATION FOR A PERUtT.WOT vat[D UNT1L PxOCE59ED
I hereby appiy for a bui[din,� permit and I acknowledge that the infurmation above is camplete snd accurate; that the work ►vill be in
ebnformance with the ordinariees and codes of the City of 'dley and with the ]vtinnesota Canstruction Codes; iltai T understand this i� not �
permit but only an application for permit k is o to start without a permit an site; that tht work will be in accqrdance with the
approved plan in the cese of a k�ht� requires v' w nd approvai of plans. �p�,,,
S�GNATURE Ol AFPi,�CANT .�. PRIN'1' NAMF, •Y, � �C ��` pATE S`t�-'< <
APPRdVAL INSPFCfOR SIGNATURE /�"'��