P - 45209.
�
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE / ' CP ' �
SITE ADDRESS � � �
TH1S APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
IlVSURANCE
PROPERTY TYPE
PERMIT TYPE
. TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-20] 1
YOUR E-MAIL DDR�ES�S,j
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❑ OWNER C�NTRACTOA C
Qil�t
�ESS 'y�v� ,� . %% � .
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NAME: L�d'yY� /U
STATE LTCENSE # n �
PHONE (Os�� %S�-ciZ�pL`d
�NGLE FAMILY N
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAG
O BASEMENT FINISH 7[�KbOF
❑ DECK ❑ SIDING
❑ NEW HOME CONSTRUCTION
F�-tOf �A IN T EN AN C E/RE P A I R
0
❑ ADDITION
❑ REMODEL
LEAD CERT NUMBEbt
FAX �pS�J��S�
sizE
STOR]ES
❑ WINDOWS
L7 DRAIN TILE
❑ OTHER
�./a �� ° �
PermitNo.f ,��(�--�r �
Received By: �� Y
Date Rec'd: � � � ,
STAT�N•ZIA �J��� �
_STATEiII"! N ZIP
I. DESCRIBE WORK BEING DONE: CJ � f=/C. 00
' SIZE OF IMPROVEMENT NGTH IDTH HEIGHT S FT
ROOFING 2 ❑ HOUSE ONLY
I NUMBER OF SQUARES �✓ LA' 1F�OUSE & GARAGE BAS£MENT REMODELING SUBMIT:
— 1. Existing Floor Plan
�� GARAGES O ATTACHED GARAGE 2. Proposed floor plan
I PROPOSED SIZE: � DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CQNSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT
O Vinyl ❑Soffit ], Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim and proposed project.
❑ Other ❑ Fascia 2. Two sets ofconstruction plans
WINDOWS 3. Enerey Caiculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS�DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUM$ER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE CO5T OF LABOR AND MATERIALS:
SING THE 1 7.B.0 FEE SCHEDULE)
TOTAL JOB VALUATTON $ Q� . a`� OCCUPANCY TYPE
Permit Fee $ '� 'S See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .00I times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
� License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
_ Curb Cut Escrow $ ft+ 6 ft= ft x$24 =$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Nacessary O
Total Due $ �`y ��— Make checks payable to: City of Fridlev Attach Stinulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City o Pridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an appiication for a permit and work ' not to start without a permit on site; th t the work wili be in accordance with the
approved plan in the case of all w hich re ires ie and approval of plan . � Y�• I'
51GNATURE OF APPLICANT PR1NT NAME DATE �
APPROVAL INSPECTOR SIGNATUR
PLEASE NOTE: SEPA TE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK