P - 60326�vv ��,,,, Frvmu612 5228330 Page: 2/2 Date: 415/2012 9:20:13 AM
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Bu�lding BUIY.DI�TG ner�;trro.:�o —d0 ,
� Inspections �i ��D�ly'���L APPLICATION Received Sv:
76�-572-3604 CITY OF F+RI�LEY �a�e Rec'd. Z
76�-soz-�9�� Fax
EFFECTIVL^ 1-1-2012
n.i-rc �l �1.1 � I .7 ...
S1TE AUDRESS �
THIS A �PLIC,4NT IS:
PROPEItTy Qji��
TEn AN'T
SUB�71T,a, COPY OF
YOUR STATE LICENSE
.�ND CERTIFICAT� OF
lNSURANCE
PROPERTY TYPE
YOUR t-MA1L ADpKESS
I� 1�;� .�
� 014NER
P}]ONE:
�
_� !� L7. i-`L�% �7'A
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37'ATE LfCEhSE #�[�. j;s ,2 1_, � S� j LEAD CER7' nUl1•iBF.1i '�Jl'" -"' s
L_2.L� Sa�{EYP; ��-- -,Zii- l �
.annxcss _5311.a �� r H S J" :� c ... clr�•,�y1 r,iv�..� vnLlCsrn�•e�zrP.�.S�L.�}-
pu�,�.,� , ; .-, , . .., i. . , ..
s1NGLF FAh�4iLY1NEt5r CONS'TRUC'f10N
'il�'O FAM[LYINE�YC�NSTRUC'!!dN
❑ BASEh+1E�]"I'F[N[SH (d'ROOF
❑ DECK ❑ Sl�ING
O Sl�%Ih2M
TYPE OF ��°QRIC: ❑ NEti1' HON1E CONSFRUC7'7pN p A,bDiTION
L7'"VIA1N'fEn�ANCH;REP.�12 ❑ REMODFLlNG
DESCRIBE 1?4'ORK BLINir D01�E: � � y .;F p-.� ,< '1 '
i r ���
SIZE OF fMPRO�'EMEId'f •' ' r y,+;t � LENGTH ���nT�{
R FIYG t Ly1-IOUSEONLY
'JL�41BER OF S�U,qRES �_�, ❑ �-IOUSE & GARAGE
.ARA ES OATTA(;HBDGaR4GE
YROPCISEDSiZE: ❑ DETACIiED G.4RhUE
PiROPUSED HEItiHT:
SIDING
L1 VinyT
O Alumim:m
� OU�sr
1�Y(14T1)Li3i�'S
�I EX15TfTIG OPENINGS �Yes ❑2�0
QR FOR I�EW QPENITTGS-D�SCRiBE SI2E OF
CiP�N1NG CHANGES fi
TYPE 4F WIND014' T'O BE tNST��LI,ED
ALL ls'EES ,�RE BASED DiV tiT,
1'f?Tr�L JflB YALI
�
Pennit Fee
Plan Revie�•
Fire Surcharge
Surcttairge
License Sureharge
St1C Charge
Curb Cut �scraw
Erosion Coe�trol
Park Fee
Sv��er Main Gharge
Tota! Que
OSoffit SIDIYG!SOFF[T/F�SCjp
❑ Trim RENIOVED� ❑ YES O A'U
❑ Flscia
LOC.%4T10Y OF WIND0�4'S
VUI�•IBL•R OF W'INpOt�'S
CIO;�i, iNCLiJD1NG THE COS'1' OF
TFIE 1997 U.B.0 FF:E SCTIEDTJT,E)
Ea DRr1IN'l7LE
0' C?TIiER
B.45EIv7CNT RLhiOUL'IrJ]tiG S,UB�fIT';
I. Lxistiug Ff�or Pian
2. Propos�d fioor �fan
3. Lis1 of stnx:t�ml mernF+crs ro be uscd
FOR NE1�' CONSTREiCf10N IN�LUDING DECKS.
AD1�tTIONS $ PORCHES SllB\4fT
i. Site P(�it�$un•Cy €twwing tly� existing strucnaes
and proposu} proj��t.
2. Ttvo sets oPconstruction p��ns
3_ Cncrgy Gniculatiomx
FDR W}NDO�VS - PRDVILSE U-VALLE AND
MANL1'F,�CTL�RF. STICKER ON 1ti7NDf?W.
� `�" I 1.5 Se� Back Page far Fce Schcdule
$ 65% of Bailding Petm�it Fee
� .(101 times thc total jc�b vali�ation
� _0005 x Pcrmit Valuation h4inimam or ,50
$ �? �5.00 (Statc Licensed Residentiat ContracCOrsy
$ $2365 per SAC Unit (Pians to i�TWCC for deterrnination)
5 ft+6ft= ftx$25=$
S $��0 Consetvation Pl�n T2eview
$ Eee Detennined by En�;ineering
� �4g€semcnt neccssary ( ) Non Neiessarv ( )
� �,p� 11�Iake checks payable to: City of Fridlev Attarl
THIS TS AN ,�iPPLTC.ATION FOR A �ERMIT-NOT V.qLJD t'VTIL PROGESSED
1 liereby apply for a buildin� permit and 1 ackno�vlcdge that the informatian above is complete and a�ccuraEz; tftiat the work will bc in
confRrmance with thc orciina�ces and c�des of the Ci f Fridle}� and �a•ith the Minnesota ConstnECtion Codes; that T undersland this is not a
permit but anty an applica#ior� for a�ccm(t nd��uo s not t� sfiart without a permit an site; that the work �vill be in accordac�ee with the
a roved ian rn the case caf,,,�ll�au rk � i�' izc view and appr�val of pians. ...,.-''j � /,� f
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S1trMATURE pF.�PPLIC.�1iT � PRINTI+AI�1E .'J�F i' �^;l' I� fi' Gs`-#'( L nA3[�"":� "- InC �
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