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Building
�nspectiQns
763-572-3604
763-502-4977 F�X
DATE l 1— I'"' � U
SITE ADDRESS _�
THIS APPLICANT IS:
PROPERTY OWNEx/
TENANT
BLTILDING
'1ZES�DENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 7-1-2010
YOUR E-MAIL ADDRESS
� l �e r, V.J o.� �� �
❑ OVWNER
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PHONE:��
CONTRA.CTOR NAME: U.1 � 1�
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE
�ND CERTIFICATE OF ADDRESS; �I
INSUR.ANCE pHONE `
�G�NTRACTOR
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w� e
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aor�A3�i��
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Permit No.:' '0�
Received By.
Dat��Re��d�� v �
2 G�� 0.� 1
CITZ' STATE ZIP
85
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PROPERTY TYPE ❑ GLE FAM�NEW i;ONSTRUCT}ON
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ ADDITtON ❑ G�G�S��
❑ BASEME�iT FINISH ❑ ROOF
� DECK ' O SIDING
❑ SW7viMING PC
❑ NEW HbME COINSTRUCTION ❑ ADDITION
EXP DATE
SIZE
STORIES
ows
❑ DRAIN TILE
❑ OTHER
s�o
�cMAINTENANCE/REPAII2 ❑ REMODELING
DESCRIBE WORK BEING IDONE: r-Z Q W 1 11� c�. c� � S - �1.0 j 5 O h i�'! � S
SIZE OF IMPROVEMENT LENGTH VaIDTH HEIG S FT
itOOFING ❑ I-IOUSE ONLY BASEMENT TtEMOD .1.IN S MIT
NtiTMBER OF S��UARES ❑ HOUSE & GARAGE L Existing Floor Plan
� ' ❑ ATTACHED GaiRAGE 2. Proposed floor plan
PF OPOSED SIZE: ❑ DETACHED G�RAGE ` 3. List of structural members to be use�d
PF:OPOSED HEIGHT: O h�, 20.G h�
SIDING ���, O� ms t FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Sor�'it ADDITIONS, & PORCHES SUBMIT`
❑Aluminum ❑ Trim a L Site Plan/Sucvey showing the existing slructwes
0 Other ❑ Fas�ia and proposed project.
3 2. Two sets of construcdon plans
�i'INDOWS 3. Energy Calculations
IAI EXISTING OPENINGS �Yes ❑No ! LOCATION OF WIN� OWS n FOR WINDOWS - PROVIDE U-VALiFE AND
OR FOR NEW OPENINGS-DESCRIBE S1ZEjOF YY�0.�� Y� `2 V�pX MANUFACTURE STIGKER ON WINDOW.
OPENING CHANGES &
T5'PE OF WINDOW TO BE INSTALLED �� NUMBER OF WINDOWS �
ALL FEES ARE BASED O1�T VALUATION, INCLUDING THE COST O� LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
T(7TAL JOB VALUATION $ CP 9 OCCUPANCY TYPE
Pertnif Fee $ % 5ea Back Page for Fee Schedule
Plan Review $ 65'% of Building Permit Fee
Fire Surcharge $ .00�1 times the total job valuation
Surcharge $', .00�OS x Permit Valuation Minimum $5.00
Lecense Surcharge $'i $5 .00 (State Licensed Residential Contractors)
SAC Charge $' $2I00 per SAC �.1nit (Plans to MWCG for determination)
Cnrb Cut Escrow $; ft+ 6 ft= ft x$24 =$
Erosion Control $ i $4�0 Conservation Plan Review
P�rk Fee $'; Fee Determined by Engineering
Sewer Main Charge $' Agreement necessary O Non Necessary O
Tetal Due $' 0-7. Q MAke checks a able to: Ci of Fridle Attach Sti ulations
THIS IS AN APPLICATION F032 A PERMIT-NOT VALID iTNTIL PROCESSED
I aereby apply for a bnilding permit and I acknowledge that the information above is complete and; accurate; that the w+ork pvill. be im
eanformance with the ordinances andj c�odes of the City of Fridl��y and with the Minnesota Construction Codes; that I understand this is not a
p�ermit but only an applacation for a j�ermit and work is not to start without a perrnit on site; that the work will be in accordance with the
alsproved plan in the cas,e o ork whic ui � s reyiew and approval of pl s. � „ I I-1 ^ I O
SIGNATURE OF APPLICAT T RINT NAME �a Y� c� SG rn i� S j r��ATE l l
A.YPROVAL INSPECTOR SIsNANRE