P - 42272Building � BUILDING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502�49%7 FAX EFFECTIVE i-1-2010
DATE G.r �2 � J�% YOUR E-MAIL ADDRESS
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THIS APPLICANT I3: � OWNER
PROPERTY OWNERi
TENANT
COIVTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTTFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF R'ORK:
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES _
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PHONE: 7G; s% i 3�O J�
NAME: �./�%G[L /JV 9 rc�t/ �..�.
STATE LICENSE #
PH� 9 rz ' 9 33 G 3 a�v
INGLE FAMILY(NEW COIdSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
O BASEMENT FIDiISH O ROOF
❑ DECK Q SIDING
❑ NEW HOME CON3TRUCTION
❑ MAINTENANCF/REPAIR
N
SIZE
NG POOL
❑ AD�ITION
Q�l�i�`MODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
Permit No.:/,�.�%l UZ� (
Received By:
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STA �✓ZII'ssy3�
EXP DATE
c'�'�'�Ga vr.r �i A.t X TA7E �� ZIP S i�S�%
_�
❑ DRAIN TIL,E
❑ OTf�R
' S ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE /J
PROPOSED HEIGHT: /� /%.�'1
S ING � S� �l.ti �s�
❑ V�YI ❑Soffit �/ �
❑ Aluminum ❑ Trim _ / �` I / .� �L./G�
❑ Other ❑ Fascia �7
wmmows /' y Ip,p�:
�i
BASEMENT REMODELING SUBMIT•
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FORNEW CONSTRUCTION INCLUDING DECKS,
ADDTIIONS & POR�CHES SUBMIT•
1. Site Plan/Survey showing the existing strttctures
and proposed project
2. Two sets of constirruction plans
3. Energy Calculations
IN EXISTING OPEAIINGS Yes allo LOCATION OF W$ FOR WINDOWS — PROVIDE U-VALiJE ANp
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE 3TICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED /O NUMBER OF WINDOWS ��
Ai.i. FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
2(�ISING THE 1997 U,B.0 F'EE SCHEDULE)
'OTAL JOB VALUATION $ �,�. /U _ OCCUPANCY 'TYpE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Ctrt Escrow
Erosion Control
Pazk Fee
Sewer Main Chazge
� `lf1"J • 1.�'J See Back Page for Fee Schedule
$ 65% of Building Pernut Fee
� �.001 times the total job valuation
S .0005 x Pernut Valuation Minimum $.50
$ $5.00 (State Licensed Residential Contrractors)
� $2100 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$22=$
� $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
� � Make checks payable to: City of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclmowledge that the information above is complete and accurate; that the work will be in
confarmance with the ordinances and codes of the City of F' ley and with the Minnesota Construction Codes; that I understand this is not a
pernut but only an application for a permit and wor ' not start without a permit on site; that the work will be in accordance with the
approved plan in the case of a11 w which re ' s re '� and approval of plans.
SIGNATURE OF APPI,ICAN �r PRINT NAME�o�''__����+�'� DATE G'�Z Y�I D