P - 39633Building BUILDING Permit No.: —d l`7��
Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604
763-502-4977 FAX CITY OF FRIDLEY nate Re�'d: � '
EFFECTIVE 1-I-2011
DATE � 1 � w YOUR E-MA1L ADDRESS �JUtil vl,��C� �� ✓i$-P�(/1� ('L . ` �°��
SITE ADDRESS � I�GI/J .�
THIS APPLICANT IS: ❑ OWNER
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LtCENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
I►GI�I�II
,�CONTR.ACTOR
� � % c�
ADDRESS: C�� L I c%�"Y/ �`'�D r'1 ��' ,. .+V E CITY ��' / c� �� (:�` STAT�%ii ZIP ,� Z
PHONE: �7Cv � � ��.� —Sr� SS � —�
NAME: (? ( P v
STATE [,ICENSE #
PHON ; `%�`�-�''/r�/ �, OC� C ,
�INGLE FAMILYINEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
�� f
LEAD CERT NUMBER � �J � T
CiTY� ��'�+ I� STA'
��/FAx '�'e�j - 5 �!� - � �v2
SIZE
PERMIT TYPE � �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF ❑ DRAIN TILE
❑ DECK ❑ SIDTNG ❑ OTHER
❑ SWIMMING POOL
- _
TYPE OF WORK: ❑ NEW HOME CONSTRUC710N ❑ ADDITION
❑ MAINTENANCE/REPAIR (�'(�EMODEL
DESCRIBE WORK BEING DONE: K P —
ROOFING
NUMBER OF SQUARES _�� �
GARAGES �� �
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
OF WINDOWS
�SS�''2 �
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ - z S'
$
$ Z J
$ �'�^
$ �� �
$
$
$
$
$
$ o .�
See Back Page for Fee Schedule
65% of Building Permit Fee
.QOI times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks pavable to: Citv of Fridlev
Attach
THIS IS AN APPLiCAT10N FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of t e Ci of Fri ey and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permi and o start without a permit on site; that the work will be in accordance with the
approved plan in the case ork i' qui nd approval of p�} s�. / %��
SIGNATURE OF APPLICANT PR NT NAME �alO+�r.wN.m�, a.✓�) k(G/�]9ATE 'L�
APPROVAL INSPECTOR SIG U /1