P - 62696Inspec�iQns
76�-5?2 :3604
SiTE At)DRESS �
'TNIS Ai>PLICANC[St
TENANT
B►ITILZ%Il�Ci
FtESiDEIYTIAL A�'PLICA"�IO�
�ITY iJF FR
YOL1R E-t�A1L ADURESS
C i�.t�a f��G
�OWNER �1iGOTITRACTOR
'� _�..f �
4VP1.11�A�4:1'VR a��iaG�w W s�� :�3ii�i�! DR'.il.
��i
' STATE LICENSE ii 1920 County Rvad "C" West
StiBMIT A COPY OF Roseville, MN 55113
Y�UR S'iATE LICEIYSE Ai3DR�s5:
wr�t��.icA,�orr ,,�o�,� License #BC13098'3
PRCIPERTY TltPE s�l�c�,���a�cvnv�� +651-ZG4-4?7?
O $��N7ENf FiN73H O RQOF
O DE�1G O SIAII+f
nESC�E wo� sFarrcc
sQu,v�s
�,�'oi.
PRl)POSED SiZE:
PR{)POSED Fi�1GtiT:
C7�
G Atuminum
Q OQaer
�3
rN E?nsTtxG �PEMidt`.s �res oNo
4R FOR NEW 4FEhi1NC'�S-DESGRIB$ 3IZE OF
Pl� Review
Fire 3urcharge
Surcharge
License Stu�cha�e
SA�G Gharge
Curb Guk F.sGrow
Eros�n Control
P�rk Fee
Sewer Main (�arge
Per�i#
y�.r�k.��-
STA'1"� .2.IP'
r s�Axe�i�
D i)RAIiti Ti
� OTHER .
e
a t�ous� ac �,4x.ac�
� A7"I'ACk1ED tiARAGE
C] DETAfHED(iARAGE'
flSoiiis
0 Trim
❑ Fascia
LUCA"ClON OF W[NDOWS
�
wn�rr� -� cos�r oF
U.ByC FEE �CH�DULE)
i. ExisdngFlaatPlan
2. t�opo�ed tioer pira
3. Lmi ofauuctutel roanbers t4 L� wed
F�R, NSW L'�}NSTilIiC`1'ION Ib[iCLUDINO flECKS,, '
A��'�(JNS_ & PCSR[_f�iFC Ci {�M]T�
1. Sita PIu�3�uvay sLowi� tl� ex�dng tu�te�dure
s� i�a'oAOSCd 1ttoJe�t.
2. 'fw�o seFS �coash�uclion Pl�ne
3. Laet�y C�atcnhtions
5�oe BackPage 6or fiee 3chedule
659�0 of Building I�ermit F�
.001 times the tc�tal job valuaticm
.U005 x Permit Valuetion► Mini�nurn $.S(}
S5.0f1(State Licensed Residdttial Ca�sctars)
52554 per SAC lln'st {�lans to MWCC far d�te�rnination)
ft-+6R= Etx�2laS;
5450 Conservation Plen Rcvierv
Fee I�ceerm'sned by Eng�emxg
Agree�zent nccESSary { ) Non 1'+7ecass�ey ( )
M�1+uG cie�ks n�svable toe C##v of Fridlev Attac
THIS i5 AN APPLICATIDN FOR A PERMtf-h1C71' VAL(Q UM'F[, PRGCESSID
I hErelry apgiy for a buildir�g pe�rnzit and I ackaowledge t'hat the infarmatiaz abov� is +a�mplexe and accun�ete; xlmt the work will be is
canfarrna�nae wit�h the ardinances �d codes of the Gity af Fridley and with the Mu�nesota Construc� Codes; t�t 1 un+de�stand This ia t�at o
pesmit laut cmly an application pennit �d work is tw�t to start withaut a petmit; that th� work will be in accordance with the �ppm�c
piat� in the case of aEl work whi revi approvat plans.
SlCiNANREUF APPLIGANT NAME/1 Z'CC�.�1AS�tf�`� �pATE_,,,,� 1, ���
� . _� ...... < Wci tr4�£���. �iOZ/£4Jtr �ai�d � E!� :a�ed.., 06491�L9LS9 :u`ao�� . . ... _ , �..., ... . _�..