P - 44977Building
Inspections
763-572-3604
7G3-502-4977 FAX
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STTL ADDRESS
TH(S AYPL]CAI�'T IS:
ERTY 4WNER/
TENANT
CONI'RACTOR
s�sn�r A copY ar
YOUR STATE LICBNSB
AND CERTiFiCATE OF
WSURANCE
PItOFERTY TYPE
TYPE
TYPE OF
D£5CR1$E WORtC BEING
SIZE OF 1NiPROVEMEM'
From: 7634244833
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Page: 1/3 Date: 11/19/20Q9 10:22:30 AM
OO�tiNER �CON7RACTO�IR v
NAME'- 7`G7 N`� f!'^l�T l'7�!l��Li
ADGIRESS:
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❑ NEV4' HON1E CONSTRUC N ADD
❑ MAINTE'VANCEIK�PATR REMOI
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NU\RBER dF SQUARES � �
GARAGES
PROAOSEA SIZ6:
PROPOSBD HEIGHT:
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Permit No.
Received By:
Date Rec'd:�
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crrv G' i2,r'�,�r.�L srnr� �r�z�p �S'y2�
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1] DRAIN TIL�
C3 OTHER
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1. sx' ing Floor Plan
2• Proposedfloorplan
3. List ofslructu�ai mcmbers to be used
FOR N�W CONSTRUCTION tNCLUI�JNG AF.�KS,
ADD3TIONS .@ �9RCHE.S Sltt�MlT•
!. Site P']aNSurvey showing thc exiscing StructuroS
azM proposed project.
l. Two seisofconsuruction plans
3. Energy Caicuiations
ALL FEES ARE BA5ED ON VALUATION, INCLUDING THE COST OF LABOR AND MA
(USII�iG THE 1997 U.$.0 FEE SCNEDUGE)
COTAL JOB VALi' """"'
Permit Fee
Plan R.evizw
Fire Surchaa�ge
Surcharge
License Surcharge
SAC Charge
Cr�rb Cut Escrow
Erosion Con�-ol
Park Fee
Sewer Main Ct�arge
_� 1 j I � d 5 See Back Page far Fee Schedule
$ 65°/a of BuiIding Penr►it Fee
$ r `.00� times the total job valuation
� , .0005 x P'ermit Valuation Mit�imum �.50
� $5.00 (Sbte Licensad Residential Contraciors)
$ $2Q00 pa- SAC Unit (Plans to MWCC for determination)
$ ft+68= ftx$21=$
� $450 Conservation Plsn Review
� Fee Determined by Eng'rneernng
� A�reement necessa�}' C) 1�Tan NecessarY E)
_$ � Make checks payable to: Citv of Fridlev ,►�t��
'CH1S I5 :�Iv APPLICATLQr FOR A PERM(T-NO'C VALID UN'fiL PRaCESSED
I hereby app(y for a building permit and i acicnowledge that the infonmation abowe is complete and accurate; that the work will be in
confonmance with the ord.inanees and codes of the Gity of Fridley and with ihc Minnesota Conshuction Codes; tttat t understand this is not 8
permit but only an application far a permit and work is not to siar! without a pennit on site; that the work will be in accordance with the
approved plan in the case of a ork which uires e' � and approva� of ptans,
SIGItiATUtiE OF APPLICANT � PiUNT NAML 1
_�J..�.,�t�,Q�;,� "e° f DAI'E
VOTE: