P - 43793From: 6512281052 Page: 1/3 Date: 10/10/2011 1:44:53 PM
Building BUII,DIl�TG
Inspect�ons ��I��NTIAL APPLICATION
���-s72-36Q4 CITY OF FRIDLEY
763-502-4977 FA� .._...._.__ . . __..
Pemut No.:
������� ��:
, , ; . �
�
--
Y7AT'� /�`' (o I 1� YOUR ErMA1L A.�n�SS �.�id-w G� �-' 7'�r+s�r�li �(+,�t[.. �.a•�-1
Sl'7'�? ADbRTsSS '7�Z.c �'�,, c,p„r� �uru�t l�f �
�TS APPLICANT TS: ❑ 0'1�V'N�R �ONTRACTOTt ~
PYtOp�RTY OWNER!
TEIVAIVT
CUNTRACTOR
SUBMCT A GOp'St' Q�
�'O'UYt: STAT'� LiCENSE
AND CERTiFiC�►TE OF
lrrsr�ir.a�'�1E
����
�*�..
'� DESCRI�E WORYC H�G
n�.a�t�.: C�v.�- i-+�,�.d . —
A�bTtPSS; C1TY STATE ZIP
pHONE: �—
STATE LICENSE #__ �"� r/Q"�m a'7 �,�!►b C�RTNUM
,aDDRES3: �D�� �. Ms�rL� S'�3r^�:p� C]TY
P�QN� C�/2•-'7ol�Lra2(o3 AAJt ��3-
o SWc��.E �aMU.�rn�r��v CqN'sTRC�C�o�v syz� --
0 TWO FAMILY/IYEW CONSTTtC7C7"lON' STORIES
O BA5EIN�NT �TNiS� �ROOF
0 DECK ❑ S1bT?+iG
Q S'W1M11A
� F sQv.ax�s �
4 E
Pi$€t�'bSED SIZE:
p�3�4SS�b r�c}iiT':
�
ov�
C3 ,Si�meaaura
o cnn�
hTEW HO1VI� CO2�1'ST1tUCTIQN
0 ACS�iTTTON'
�tEMOi3ELYNG
D 1��L1T15� ONZY
;�HOUSE � (3ARa.G�
0 AT'i'ACl-TEn l3A�AGg
0 DETACHED Q�412AG�
a8ctfi,r
o r�
C] Fascia
�1' �7CKSTlNd OP'ENITKiS QYes CI1«�o Y...00ATIDN �F WINDO'WS
Ol� �`f?� N�'W OPENINCr3-DESCRiBE S►z� OF
�Pb'NINCC�i C�YANGBS Bt
r'Yl'E OF W1NflOW TO i3E YN'S7AC.1.P1� Nt)MB�t Oi�'WTI�TDO'9V3
Aii ��ES ARE BASEd ON'VA�.UATYON, TNCLUDING THE COST OF
.�� . � ..__ ..� _ � ..- --- - (usr�� � �9�� v.s.c �E sc€t�n��
pennit Fe�
1'�m Rev'iew
� s�
surcharge
Lir�se Surcharge
SAC Ct�arge
Cvrb G'ut F,scrow
Fxasiun Cont�+pt
1'�rk Fce
Sewer Main G3�Srge
Total �ue
$
0 DRAfN TILfi
❑ OT'iiL32
,� _
��a c3
�ASBMEN'i ��tt�aT.n�i� S�L1t�1vnT�
1. Extsring Floer Pl�e
Z. PtaP�� tloor plu�
3. iist af sau�q�ral mem� 1ar 6e j�sed
Y�t� fJEW GONSTRUCTi�k3N 1NCC.r1�1II+T+G n�C:S,
�1CTTdN'S. � Pt�Rl;HR.R S3i�
i. SitC Pl�n1$wve,Y St�ow�ag �e'CX�sp6g SA�re6
�,a �o�a w��
a. 7Y!vo sets af �ica p1aAs
3. Bncrg,y C�Iqtletkrns
FOR 1NIND0'11VS -1�RQ'V'!DL U-VALUE AND
MANUPAGTiJRE S'T'iCl�t QN Wi1�1�7pW,
TERIAi,.S:
65s/o of Buiidittg P�mit Fee
.401 times tbe t�tal job vatu�tian
.oaos � ���t val�� ���m �s.00
$S.UO (State iicensed Residential Contractors)
�2230 per SAC Unit (Plans ca M'"�V'CC �Fo� determiaation)
ft+6f��� ftx$25=$
$4SQ Conscrvation �lan Rtivi$r�v
�ee DoC�rminod by �ngine�rir�g
Agreement neccss�' i) Nc�ti Necessary' f)
Make check� paysble to: C�t� of`Fridley Attach
Till,S [3 AN .'4F�'WCAT[ON �OT{ A P�1tMyT•NOT VALID UIVTIL PRflC�SS�f
I herebY a�►pPY for a building p�ttnit and C acicno�ledge that the inforcnation above is complete and accurate; that the vvorlr will be in
confoemartce �c�rit� the �rdinances at�d codes af the Ciry af F'ridley aaid with the Minnesota Construction Cades; that 1�dersta�nd this is not a
P�t�nit but only au applic,�ticm for a pemzit and wark is not Co stazt without a permit on site; that Che work will be in accordenee with thg
�pp�rcru� plsn in the csse of ail w u�es revie�cv snd appro�val af plans. .
SIQNATlI� [� A�T.yCANT ��� PRINT NAME �e-� !''Z�ts•� DATE r �"�,' " tl
e1�DOAVa� tnrs6�r�rnn erra^�.rwmr�rv�n � � �
a`S�