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�.uilding
�nspections
763-572-3604
763-502-4977 F�Y
DATE���
SfiB ADDRESS
THIS APPLICANT IS:
BLTILDIN�
Permit No.
'I2ES�DENTIAL APPLICATION Received By:�
CITY OF FRIDLEY D�$���&�V 2��01�
EFFECTIVE 7-1-2010
YOUR E-MAIL ADDRESS
c; Y�'�' O}"� �.._," �� . ��' t- r i CI
❑ OVr'NER �C��NTRACTOR
�
P'ROPERTY OWNEB/ NAME: :.5uj e S �-i-�- c� r, c� � n Q . C q.-}-{`.�,u,-..0 � C' 2 f
TEN.�NT �b�ss: �-7 ��'ro,-,.�-cn S�, IV ci���-t d L� �, sTa�VYy1J z�r 55 �l�
PHONE: �OSJ �, y5 G��(�p
CONTR.�CTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
�ND CERTIFICATE O�
INSUR.ANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SI�E OF IMPROVEMENT
ROOFING
PdUMBER OF S��UARES _
G�RAGES
PF:OPOSED SIZE:
YF:OPOSED HEIGHT:
1rs. �a w L. o r
STATE LICEQNSE # � � I
ADDRESS: -I � C� LC�
"I ` EXP DATE � -' � I -" �'
��,� d� eJ'�°�- �1� CIT'Y ' 0.0 Ct STATE/�i� ZIP J_'����� �
� I o� FAx a r I q c� �-a` I`7 �-1 t.�
�INGLE FAM�EW ��ONSIRUCT}ON SIZE
❑ TWO FAr✓IILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED �WINDOWS
❑ BASEME�iT FINI�H ❑ ROOF ❑ DRAIN TILE
❑ DECK `�(SIDING ❑ OTHER
❑ SW=MMING POOL
❑ NEW HOIvIE CONSTRUCTION ❑ ADDITION
�j;MAINTENANCE/REPAIR ❑ REMODELING
's:_ �\C�,�r�cl � �2.r��a.C�._ �.,.�iY\�d�1S' �Yl �'ZC(S
LENGTH WIDTH HEIGHT
SIDING
�Vinyl
❑ Aluminum Fro r� t C/1 � l�
❑ Other
�VHNDOWS
IIV EXISTING OPENINGS �Yes ❑No
O1�FORNEW OPENINGS-DESCRIBE SIZE,'C�F
OPENING CHANGES &
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GeRAGE
❑ IIETACHED GARAGE
❑Sotfit
D Trim
❑ Fascia
LOCATION OF WINDO�'VS r-y l I�., C I _�
l.�(, �[��t�t r(L
• • �� �
.�
BASEMENT REMODELING SUBMIT
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be use�
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SLrBMIT•
1. Site Plan/Survey showing the existing slsuctures
and proposed project:
2. Two sets of construction plan�
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE ANI7
MANUFACTURE STICKER ON WINDOW.
TiTB OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS U �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS•
TO'TAL JOB VALUATION $
Permit Fee
PLan Review
Fire Surcharge
Surcharge
L'acense Surcharge
SAC Charge
Cnrb Cut Esca�ow
Erosion Control
PGrk Fee
Sewer Main Charge
Total Due
(USING TH� 1997 U.B.0 FEE SCHEDIILE)
`� I � � C7 � OCCUPEINCY TYPE
$' '!.p'��, , Se� Back Page far Fee Schedule
$ 65'% of Building Permit Fee
$' .00�1 times the total job valuation
$ �-{ .00�OS x Permit V�luation Minimum $5.00
$ c� � $5 00 (State Licensed Residential Contractors)
$ $2200 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ ' $4�0 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ � g5 ,�D a Make checks qayable to: Citv of Fridlev Attact
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I_lereby appfly for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
canformance with the ordinances and' codes of the City of Fridl�y and with the Minnesota Construction Codes; that I understand this is not a
�rermit but only an applacation for a permit and work is not to start without a permit on site; that the wark will be in accordance with the
approved plan in the cas� of ork which re ' iire revigw and approval of pla � O
SIIINATURE OF APPLICArT V�%'�-��- NT NAME��a YLC� �� JY1KS jY ��-� -
R.PPROVAL INSPECTOR SI3NATURE
I'L�ASE NOTE:� S�PARA ; R . A}�F,;RF.(1TTTRRT7 Ff`1R PT:TTMRTNC+: FT F('�TRirAT ahTTl x� er' xT
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