P - 44963Buil.ding
Inspectians
763-572-360�
763-502-�977 FAX
From: 7634344933 Page: 2/3 Date: 11/15/2010 2:45:25 PM
B�UIL�YNG Permit �vo.�
R,ES�DE�TTIA.L ��PLICA'T�ON R�����
CI�'Y' OF F�ID�.EX Date �ec d._
DAi'$ e� -• YOUR E-MAiL ADDRF,55 �ih V P A-.1�4
SiT� ADDRBSS �, V „� I� t V t"-JZ-'V \�-V1 �f �.•fa RPt�
TFRS Ai'PLiCANT TS; O OWNL•it �4TI7'RACTQR
PRffPF.R'FY OWNE.RJ �el„r�• �1�J N I � � C-- �
'I'�NANT
5UaMiT A corY OF
YOUR STATE LICENSE
AND CERTIL•'ICA't`F OF
uvsuRn�vc�
�F,(tMI'1'
OF WORK:
DESCRIBE WORK 88iNG
STATfi L.jCEN3E �t � U
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i r�
i FJ"{�Z. S T
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O 31lHGLE FAMILYlNEW C[aNSTRUC'['i0N
p Tw0 FAMI�Y/nTEW CON3TRUCf10N
f� BAS�MENT SiN{31S O RpOF
❑ DECiC D 51b1NC*
� Sw1MM1NG POQi�
p NEVJ �H�M� CQNSTRUCi'1t7N O AD171TI�N
O MAfN'f'ENANCElELEFATR 0 RFMODELINd
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F.XF DAT$ _ % � L
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ES
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1a QTHER
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SiZE t)F TM!'ROVEMisT1'P �Cl� �^ � � S � �`'� I ' . �:L�� � W� �
�t�pFiNG d HO�E OAn.Y
MlM88R Of SQUARES O I•i4USE 1t GA[tn4B
❑ AT7AC� GARAC3E
FR� 3f�s: GI PfiTACHED OARNGE
PitOPC1S6D HFitGH'f:
p�� G1Sat'tit
D Aluminum O 7rim
0 orh�r � ❑ r•�sc�a
W
IN Fs�G OPENINGS �Yes GIfTO LOCATION QF WINbQWS `� •
oR F4R NEw QPENINCS•dE3C�tBE SIZE OF
OPENiNSi CHANCE3 & .. I� , - -- — -- �
Ai..L
'OTAL JO� VALUA'
Permit Fee
Alan Review
Fire Surcharge
Surchargc
i�icen.ge Surchstga
SAC Charge
Curb Cut Escrow
Erosion Contro{
Park �ee
Sewer M,ain Charge
VALUA�
�
� W
/
aas ARENT RSM4DSLiNG SUBb�(�:
1. Eaisting Fioor Plan
2. Pmpo:aed floor pian
3, Li.vt of afit�cNcai m�mbets to bd uacd
FOR NEw CON3TRi)C7lON Ii+iCLUDiPIG DECKS,
�, 4 � �s SuswnxZ
l. Sitc Plan/S4rvey a�owing the w�isting struc.tures
and qropos�d projctt
2. Two 9ct+ of consd'tiacion piana
3, Bncrgy CA1CUl�tinns
LUAxNG THE C4STi QF LABO� AND MATERIA45:
U.B.0 FEE SCH�DULE) �
�� n„=,3 3 i�a i�i �� I� �� 5 s..:,=,_
See Back Fage for Fec Schedule
65%ofBuilding Permit Fee
.Odl tim�s thc total job valuat'tcm
,(t�pp5 x Aermit Valuation Minirnum �.50
$5.00 {State Licen�cd Residentiai Contraet�rrs)
$2000 pe�' SAC Unit (Pis�ts to MWCC for dctcnttit�ation)
i}+6 ft= ftxSZl =$
�450 Canscrvation P1an Review
�ee beterrnincd by Engineering
A,greement necessary ( ) Non Nec�ssary ( )
0
o —t� %�i
THf$ tS A'N APPLIC.4T101V FOR A PER.MIT-NC1T VALiD UNTIl. AFEOC635FD
I horcby apply fnr a building �rmit and � ecknowledge thai ihe informativn above is complebe anti accurate; that the work will be in
confarn�aace with the o�dinances and oodes of che Gity of �ridley and with thc Minnesota Construction Codes; that I understand this is rrot a
permit but only an sppliCtttion fOr pertni and work is not to start without u permit on sit ' th�t the work will be in accol�dBtteC witit the
approvECi pian in t� cquires rev#cw and approval,w€pF�ns� � 2� � ��
$iGNATURE AF ArlLiCANT ?hINT NAMEj� _�� � DA'I'E ` � 1`�'