P - 48039Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �• (:p • � /
SITE ADDRESS (y D � S
THIS APPLICANT IS:
, �, S
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECT'IVE ]-I-2011
YOUR E,�YIAIL ADDRESS
❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: b( G�.�,� L�
TENANT ADDRESS: �D �'J yt �
PHONE: [p%a• - S S U-3D/b
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NAME: ���
STATE LICENSE #
ADDRESS:� 7�
r
CERT
0
PHONE cp S� — ZSy'"= (� `-t'Cp FAX J!� /II
INGLE FAMILY N SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED INDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION � ADDITION
�AINTENANCE/REPAIR ❑ REMODELING
Permit No.:
Received By:
Date ��:
STAT�N ZIYJSrJ o�
'D S�
A
DESCRIBE WORK BEING DONE: �/'C�m.(ll_/' o_`Yl.P�.[�C — µ.�)
SIZE OF IMPROVEMENT v LENGTH WIDTH . HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: � DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑So�t ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim � and proposed project.
❑ Other ❑ Fascia �— C� 2. Two sets of construction plans
WINDOWS � (J�. 3. Energy Calculations
IN EXISTING OPENINGS ITYes �No LOCATION OF WINDOWS ��M�� FOR WINDOWS — PROVIDE U-VALUE AND
OR PGR hIEW OPE�iiidGS-I'iESC^nIBE SiZE vF ,�� /�l.Q.(h, ��—� MANUF,yCTiiRE STiC
OPENING CHANGES & �
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
ING T�1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ C� ' OCCUPANCY TYPE
Permit Fee $ f 5. �.�j- See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ . v o .001 times the total job valuation
Surcharge $ • DU .0005 x Permit Valuation Minimum $5.00
License Surcharge $ ,-�j . $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 Necessary O
Total Due $ f� '.�e� Make checks payable to: City of Fridlev Attach
THIS IS AN AP:
I hereby apply for a building permit and I ackn
conformance with the ordinances and codes of the
permit but only an applicatio r a permit and �
approved plan in the case of 11 wo c�nvhich r quir
SIGNA"I'URE OF APPLICANI'
APPROVAL INSPECTOR SIGNATURE
PLEASE NOTE: SEPA E PE IT
OR A PERMIT-NOT VALID UNTIL PROCESSED
the information above is complete and accurate; that the work will be in
ley and with the Minnesota Construction Codes; that I understand this is not a
to start without a permit on site that the work will be in accordance with the
id P,� � �MEplans • , „��f ��Wl D.�TE �P � �P • ! /
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