P - 45811Building
Inspections
763-572-3604
763-�02-4977 FAX
DATE lJ� � Z2 � � S
si� ADD�ss �3�-
THIS APPLICANT IS:
� Y �i►l[`�
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2010
aV�s
Permit No.:
vec� �
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a e ec' d:
YOUR&MAILADDRESS �-�c_-<<�(�� ���e-�<-S�fOO�Iv�C�v�'L�.j(C��yy� . CQW�
� OWNER ,�CONTRACTOR
ADDRESS: �S� � C �'i (.-��0� �C� CITY
PHONE:
NAME� �Ck's Raofing and Sidin
STATE LICENSE
PHONE F��7B$):
,,I�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAG
❑ BASEMENT FIAIISH 0 ROOF
❑ DECK ❑ SIDING
TYPE QF WORK: (❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCEJREPAIIt �`REMODEL:
DESCWBE WORK BEING DONE: �-2Gt'� O�°F� °d` ;('�' i/L cr-r
SIZE OF IMPROVEMENT LENGTH WII
ROOFING ��,,f O HOUSE ONLY
NUMBER OF SQUARES �/ J�`HOUSE & GARAGE
GARAGES J� ATTACHED GARAGE
PROP05ED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
SIDING
O Vinyl
CJ Aluminum
❑ Other
OSoffit
❑ Trim
O Fascia
WINDOWS
IN EXISTING OPHNINGS DYes pNo LOCATTON OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
ATE � il� ZIP S��I
(fiC.
EXP DATE S� JT I�%2
_CITY STATE ZIP
SIZE
STORIES
n wirmows
❑ DRAIN TILE
❑ OTHER
BASEMENT REMODELING SUBMIT'
1. Eatisting Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR TiEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS 8c PORCHES S MIT-
1. Site Plan/Survey showing the existing struchues
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTLiRE STICKER ON WINDOW.
� 1rrCVC W1NllUW lUt3�1NJ1ALL�ll NUMBEROFWINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
SING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ � __ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ ltJ `7 • f���_ See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ _.001 times the total job valuation
$ ,0005 x Permit Valuation Minimum $.50
$ $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$_ E.( d Make checks_payable to: City of Fridle_y Attach
THIS IS AN APPLICATION FOR A PF1tMIT-NOT VALID UAiTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is compiete and accurate; that the work wiil be in
conformance with the ordinances and codes af the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and work is not to start without a permit on site; that the work will be in accordance with the
approved pian in the case of al(�york�which requires review and approval of plans.
SIGNAT[JRE OF APPLICANT
PLEASE NOTE: SEP�;B�TE �R1�IYTTS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND
1� tX`2-Z'��
WORK