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From: 7636339751 Page: 1/1 Date: 6/13/2011 3:34:46 PM
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RESIDE�1"�X.A�.� ,A►.��'L�C.A.TION
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T�VAN'i' ADDRE55 %,�(�J 14kii�C' S'�'. /1i� CIT'Y,
FHUNE ��� ��I ` S�'��
�o�v�r�c�ra�
SU�3MIT A t'{}PY UF
YOIJEt S'�`A'C�: LICkNS�
ANl7 CERI�I�'ICATF UF
INSU 4tA,NC�
PitO�'�RTX '�'YPE
PERMIT TYPE
NAMIa.�^�7;�_
$TATF („ICE:NS�; k �
,n�z���ss: ! �A ,
PFIONL �C�- ��
w�ir�c�..F. Fan���.Y .
❑ TWO Fi0.�vIlI,Y/J��1A% CON$7]�UCTION
❑ ADDITION ❑ GARAG
� BASEMENT F[NISH Q�ifpc)F
❑ DECK ❑ S[BING
Per�it Nv-:
Received By:
. � _ �
-, ,
arG�.i.iv�.
C'ERT ti11�18L• R �/
[[�'V' �� �llrt-+/ $TATE �!IhZIP .�,'�1
srzL_
STORIES __
TYP� C1F WC1RK: ❑ NF.w HUME CONSTRUCI']ON ❑�nofTioh
Q.R-tA1Nl"F',JV�q,NCE�REPAIIi {3 REMt1DLL(NG
DESCRE$F 1LWORK BEING D4NE P� 1"�
SI2L OI' �h1pR()� Eh1F.NT I.ElVG'TFl W f DTH
�I� . ❑ FlOUSL C1NLY
NUMf3ER OF SQLIARFS � t 6d?iOlJSG & C�ARAGF„
r..nsACFs
PRC)PO5FD SIlE
FROPOSE:i7 H�.IGFi't" _
11 �
❑ vinyt
Q Aluminum
fl Oshcr
0 A7"TACHFp GAR.AGE
4 (?�TACH�D GARnGE
❑$qt7it
❑ Trim
❑ Fesc�s
Cl pRAiN TILF
CI (7TIdER
W FN 1}01tiS
lN EXISTING OPEN11VqS ❑Ye5 C]J�o �,C7CATfUN OF R"INDt7�1'S
OR FOR N�W OP�NINC;S-TJE5CRIBE SIZE OF
OPENING CHANGFS �
TYPE O� u11NDOU TO Bb INS'I'AI„l.,Ep NUMBER OF N'INDON'S
q�,�, F��S ARE BASED ON VRLUAT�U�, �NCl.UD1NG THE CUST OF L!
� �� (US�NG'x'k1� 1997 U.�.0 �'E� SCHEDLJLE)
'�'OT�A�. JOB VALUATION $ _ (�Oi'J � _ UGC4�PAN
Plan Review
Fire Surohar�e
Surcharge
Lieense Surcharge
$AC Char¢e
Curb Gut �scrow
E�'OSioh COntr01
Park Fee
Sewer Main Charge
�
S
$
zlBd
QASEMENT REMUf3F,;I.ING SUBMIT
I . Exisnng I'loor Plan
2 ProAased FloUr plan
3. I,�st of svuctural mcmbcrs to be u5ed
Fqk NE�' CONSTRUCTfOtv INCLUDING DECKS,
ADllITlONS & t'ORCFiF�Sl1AMIT
I. Sitc Plan(Survey ghOwln�, the ��isung :StructurCs
and pmposed prvleLi
2 Two SM5 ofcqngtrUC�ion �I�S
� EncrQ}' Calc�datlpn5
�"O�i N%Ii�DUWS — PROVIDfi U-VA4,UE AND
!UANUFAGTURE ST�CK�R 4N N'lNpOW.
AND iV�AT���A�.S:
See ��ck P�ge for F�� Schedule
45%of Building P�rmit Fee
.001 times the total jqb 4'aluation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State 1,icensed Residentisi Contractors)
$2230 per SAC Unit (Plans to MWC'C fot' determ�naCiol�j
ft-�6ft= Rx$25=$
$450 Conservation Plan Review
Fee Determined br• Engineexin�
Agre�ement neceSSary ( ) N0� iVeC�s5ary ( )
hiake checks qa�'able. tu: City of Fridley _ Attac
iHCS IS AN APPL.ICATIt�N 1�'C?R APE:R�71T-NQ'T NAI,IU Uh1'll. PRUCESSED
! h�reby apply for a buildin� perm+C and 1 acknowled�e that the in�ormatipn above is oomplete and accurake; that the work wi�l be in
conformance w�ith the ordinances ar�d c f the City of Fridley and with the N1aanesota Construction Codes; that I understand this is not a
permit but only an applicatiott for a and work is not to start without a permit on site; that the work will be in accordance with the
appraved plan in the c�se of aU w � ch requires review snd approval af plan� � J�� ���
SIGNATVItE OF ,APPI,iCAN7 PRJhT NAMt !� �'k' (%tiil��.S DATE r
SEPARA B PERN4ITS ARE REQUIR�D FQk� ��,UIv��ING. �LECTR[CAL AND MEC'HANCCAL