P - 47286`.' '�+ +/ L V/ L V 1 1/ �++ � 1 1 � 1 I ��++�+
Building
Inspections
763-572-3b04
763-502-4977 FAX
f1ATF' ID" Z O" �O � I
SITE ADDRESS �1
THIS APPLICANT IS:
T�NANT
CONTRACTUR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PRaPERTY TYPE
From: unknown Page: 1/1 Date: 10/20/2011 10:56:35 AM
1 4Ai1 NV1 VVa � ��I� 1v V�
BUILDING
RESIDENTIAL APPLx�ATI4N
CITY 4F FRIDLEY
YOUR E-MAIL ADDItESS C A Rl p@
0 OWNER �CON'CRACTOR
��...va
Permit
Received By:
Date r�c��
� V V!/ V V 1
'��
STATE LICENSE # a2D/'7 S'7/?9 4EAD CERT NUMBER
anDa�ss:12.53 CflJRS/ DR t tl� CITY u�OE�k/��/i/,'PI�STATE�ZIP_,`�.�
!o/� "�.i17-7�v
FAMiLY/NEW CONSTRIICTION
MILYMSW GONSTRUCTION
SIZ&
5TORIES____ 1
❑ BASEMENT FINISH ,�i�"it00F
I7 DECK O SiDING
E7 SWIMMING Pi?OL
OF WORK: ' O NEW HOME GONSTRUC'PION ❑ ADD3TION
' ❑ MAR�fTENANCElBEAAIR .�$'REMODELING
DESCRISE WORK BERVG
i•ru� F sQuax�s �3, �3s�
GARAGES
PROP03ED SIZE:
PROPOSED HEIGHT:
SIDING
C] Vinyt
� AltEminwn
❑ Other
WI�DOWS
iN EXISTING OPEMNGS CIYes ONo
Oit FOR NEW OPEN[NGS-DESCRIBE SIZE OF
OP&I�III�iG CHANCrES &
ALL FEES ARE
TOTAL JOB VALU
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC �harge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Chazge
�HOUSE Oi�ILY
❑ HOUSE & GARAGE
2�'ATTACI�D GARA.GE
� DETACHED GARA.GE
❑Soffit
❑ Trim
❑ Fascia
LOCATI4N OF W[NDOWS
� bRAIN'C[LE
❑ OTHER
fIt?N, I1�TCLUDTNG THE COST OF
THE 1997 U.B.0 FEE SCHEDULE)
RAfiFMRw'r' RFMODFLMC �;,(j�MIT:
1. Existing E'Ioor Alan
2. Pro�wsed #toor plan
3. List of st�uctucal members to bo t�sed
FOR NEW CONSTRUCTION INCLUDING DEGKS,
ADD[TIONS. & PORCH�S SUBNL�'L':
1. Site PlanlSurvey showin$ the existing slructures
� P�P�� P%1�
2. Two sels of constct�ction plans
3. Energy Calculationa
FOR WINDOWS - PROVlDE U-VALUE AND
MANUFACTURE STICKER ON WI1�iDdW.
$ C�'� ; L.'j See Back Page for Fee Schedule
$ 65% of Building Permit �ee
$ °��•T- .QOI times the total job valuation
$ .OqOS x Permit Valuation Minimum $5.00
$ � $5.00 (State Licensed Residential Contractors}
$ $2230 per SAC Unit (['lans to MWCC for det�rmination)
g #}+6ft= ftx$25=$
$ $450 Conservation Ptan Review
$ Fee Determined by Engineezing
$ � Agreement necessary ( ) Non Necessary ( )
� h _ Make checks uavable to: Gitv of FritUey AtEac
THIS IS AN APPLICAT[ON FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby appiy for a building permit and I aclrnowledge that the information abave is complexe and accuratc; that the work will be in
confarmance with tlte ordinances and codes of he ' of F'dley and with the Minnesota Construction Codes; that I anderstand tius is not s
permit but only an application for a permit and work n to start without a pernut on site; that the work will be in accordance with the
approvec3 ptan in the case of all ork wh' uires re 'e d approvat of pl�p s.
SIGNATUREOFAPPLICANT ' PRINTNAME t'M'YL%r4 D�l'�4�ien DATE 14��DIl!
............. ....,,,�,.....,,, �.�,.�..�..��.. /1 D
L..�r�.�k G�.� # � pt,�-to�'(�7� - (
��