P - 42848.,
Frvm: 218+723+7792 Page: 2/3 Date: 10/7/2011 11:10:16 AM
Building � BTJILDING Pe�itNo.: �ol(��
Inspections , RESIDENTIAL APPLICATI�I�' Received By:
763-572-3604 CITY 4F FRIDLEY Dat 'd:
763-502-4977 FAX
EFFECTIVE 1-I-2011 �
DA7'l; IO •�% ° a.ZCJ I I YOUR E-MAIL ADDRESS P�TR FCK, GE_LGE/� d� C E�1TU RY L 1IV K. CCXM
S1TE ADDRESS �� y�% E FlLL Md ►'LE C 1�. �� �- r� ��-7,� 3 y� �3
THTS APPLTCANT IS: �OWNER ❑CONTRACTOR �� g- 3�E�- yd�� z"
PROPERTY OWN�RI ' xaME: �7i�Jl�lJ d- A- U D�£ � I?'1 A Y�Ef�
TENANT ', ADDRE35;�S3y 7 E FILLMd@f G IIC:, rl,l �. CiT'Y F21 DLE � srA�itJ z� SS�f 3'�
pxorrE: d.s? - 3 51 !- a� 4 Z
Ct}NTRACT�R Np��:
SUBMIT A COPY OF gTATE LtCEhTSE # LE�tD CERT NUMB�R
YOUR STA.TE LJCENSE
ANb CERTIFICA`CE OF ADDRESS: Ct1'Y STATE_ZIP
INSLJRANCE PHQNE FAX
PRUPERTY TYPE O SiNGLE FAIvfILY/NEW CO.NSTRUCTION SiZE
❑ TWO FAMILYlNEW CONS'fRUC170N STORIES
PERMiT TYPE O AAAITION O GARAGE/Sl-lED ❑ WIIVDOWS
� BAS�1vIEN'I FlNT3H ❑ R00� ❑ DRAIN TILE
Cl DECK ❑ SIDING ❑ OTHER
❑ SWINlMING POOL
7'YPE aF WORIC: 0 NEVV IiOMG CONSTRUCI'lON D ADD1TiON
❑ MAINiTENANCEIREPAIR � REMODELING
DESCRI�� WORK BEING bONEs F1 N�IIISH / RDD M � N 7l�9�1f►'t E �llT' �..5 FE SL'�' 7C f�+' �
SIZ�OFi1MPROVLMENT 1,�NGTH' o�Io � W1D7�i !� f tiEiGNT r FT �
R04�'iiVG ❑ HUUSE ONLY
NUIMBER OF SQURRES ❑ HOUS€ & GARA(38 ��S£MENT REMODE(.�IG SLT�TT:
1. ExistingFloorPlan
�A1tAG.�S O ATIACHED GARAGE 2. Proposed filoor plan
FR�POSED S1ZE; ❑ DETACHEA GARAGrE 3. List af souatwal tnembas to be used
PROPOSED HEl(3HT:
ID FQR NEW COTFSTRUCCION lNCLUDINd DEGK.9,
��iayl CfSoifit An[)i!'i4NS. & Pt)RCHE3 SUBhiTT:
� Aluroinum ❑ Trim 1. Siu Plm�lSurvey showmg tha c�isting eductures
❑ Uther ❑ Fasaixi �'d PTOP��d P�'olcct.
2. Two sets of conshvetion ptans
WINDOWS 3. Energy Calculations
IN EXJST)NG OPENINGS QYes Oido LOCA770N OF WINDOWS FOR WfNDOWS - PROVIF3E U-VAi.[iE At�1D
OR FOR NEW OPENITVGS-DESCftTH6 StZE OF MANUI'ACTUItE STICKF.R ON WiNDdW.
OP�NINC CHAN(3ES &
'tYPE Or WIlVDOW TO BE FNSTAGL&D NUMB�R OF WINDOWS
ALL FEES ARE BASED (?N VALUATION, INCLUDING THE COST OF LABf)R AND MAT'�12IALS:
V
�'lan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Ctir� Cut Escrow
Erosic�n Coatml
�ark Fee
Sewer Main Ck�az$e
{USING THE 1997 U.B.0 F'EE SCHEDULE)
.� nr�rrTv
S � �q
See Back Page for Fee Sehedute
63%0 of Building Pemxit F�e
.00! times the total jab valuation
.0005 x Pernut Valuation Minirnum $5.00
$5.00 (State Licensed R.esidential Gaiitraetors)
$2230 per SAC Unit (Pians to MWCC for determination)
ft+6ft@ ftx$2S=$
$450 Gonservation Pian Review
Fee Determined by Engineer�ng
Agreement nece5sary ( ) Non t*lecessary ( )
Make cfiecks nravahie ta: Citv oY Fridlev Attach
THtS IS AN APFL1CATtON FOR A PERMIT-f30'f VAL1Ir UNTIL NROCESSED
I hereby �ppiy for a building permit and I ackn wledge that die infonnation above is complete and accurate; that the work will be in
conforrnance �with the ordinances and codes af the 'ry of Fri y and with the Minnesota Construction Codes; that I understand this is not a
permit but only an app3' on a permit id G�1. 's no t start without a pennit on site; that the work will be in accordance with the
approved plan it� the c o€ ali w•' Wti�h �. • rEvi a approval of �1 s. • ✓'
SIGNATUT2E OF APPL[C:A Pjtuv'� Iy,q.ML�Zi� /��C G�l4j Er DATC �t/� ���-r!I /
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