P - 35311Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�
SITE ADDRESS _
THIS APPLTCANT IS:
PROPERTY OV
TENANT
SUB�tIT A COPY OF
YOUR STATE LICENSE
AND CERT[FiCATE OF
INSURANCE
PROPERTY TYPE
TYPE
WORii;
DESCRIBE WORK BEING
From: 763 413 2614 Pa e: 1/1 Date: 10J20/2010 11:20:51 AM
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BUILDING
RESIDENTIAL APPLICATIIJN
CITY OF FRIDLEY
EFFECTLVE 7-1-20I0
YOUR E-MAIL ADDRESS (
.�
7 WI�lER CONTRACTOR
'� i vl
ess: �IoD � ota.dGbn dt� crr5r f'Yid J
PHONE: `�
NAME: �DU P'O�T %� '�'t� py� �[
STATE L[CENSE # %I7S1'SGI2LI-
6�SINGLE FAMILYlNEW CONSTRUCTJOIV
Q TWO FAMiLY/NEW CONS'I'RUCTION
O BASEMENf FINISH O RAOF
� DECK Yl cmrN
NEW HOME CONS'CRUCTION
B4QF3L�
NUMBER OP SQUARES
AFtA
AROPOSED SIZE:
PROPOSED HEIGHT:
D!
O Vinyi
❑ AIUCninu p� Q�(,� �t � f
l�Other';,����►�11T�cK 7�we�4s
WIN OW�S � Q+Q�,7yj�-
IN EXIS7TNGOPENINGS OYes ONo
OR FOR NEW OPENING3-DESCRIBE SIZ� OF
OPEIVIIJG CHANGE5 8c
TYPE OF WINDOW TD RF trte�ra �► Fn
ALL FEES ARE
COTAL JOB YALUA'
Permit Fee
Plaa Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosian Control
Park Fee
Sewer Main Charge
O ADDiTtON
❑ REMQDELING
O HOUSE ONLY
O HOUSC �& GARAGE
❑ A7TACHED GARAGE
❑ DEI'ACHED GARAGE
'�Soffit
O Trim
�Fascia
1.00ATION OF WRVDOWS
ON VALUATION, IIVCLUDING THE COST OF
(UJSING THE 1997 U.B.G F�E SCHEDULE)
? ► q5n . �t� .,.•,,.rs.
EXF DATE
Clri' S"j�
tt�x . :
O pRAIN TILE
O 01'F3ER
Permit No. • .� �
Received By:
Date Rec'd: i T`, �
��ztr SS�i �$
BASEMENT RE►190D _LIN S Bl�"IT•
1. Existing Flaot Man
2. Proposed floor pian
3. List of structura! members to be used
FOR NEW CONSTRUCT'!ON INCLUAING DECK3,
ADDITIONS. � PORCHEC gt rRMrr•
I. Sita Plan/Survey showing tha existing structwes
and proposed projoct.
2. Two xts pf Consduction plans
3. Energy Cakulatio�ts
FOR W[NDOW3 — PROVIDE U-VALUE AND
MANUPAC7'URE S'I7CKER pN WINDOW.
AND MA'
� 1 �l 5��5 See Back Page for Fee Schedule
$ 65% of Buiiding Pennit Fee
$ ,.! 5 .001 times the total job valuation
� � A005 x Fermit Valuatian Minimum $5.00
$ 6'� O(� $SAO (State Licensed Residentiat Contractors)
$ �2100 per SAC Unit (P1ans to MWCC for determination}
$ ft+bR= ftx$24=$
� $450 Conservation Plan Review
$ Fee�Determined by Fngineering
$ ., ,__ j.�_ Agreement necessary ( ) Non Necessary { )
a T; � �
. - - - - ---------
THIS IS AN APPLICATION FOR A PERMIT-N4T VAL ID UNTIL PROCBSSfiD
I hereby apply for a huilding permit and 1 aclmowledge that the information above is camplete and accurate; that the work witl be in
confocmance with the ordinances and codts of the City of Fridley and with the �finnesota Construction Codes; that I unde�stand this is not a
permit but only an applicatioa for a permit and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of work whi ►�quires view and approval of pl + I
31GNATUREOFAPPLiCANT,;��� PRINTNAME__�� pATE L�`�12�D
APPROVAL IidSPECTOR SIGNA
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