P - 39636Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � � �
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMTT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF [MPROVEMENT
BUILDING
RESIDENTIAL APPLICATI�N
CITY �F FRIDLEY
EFFECTIVE 1-1-2011
Permit No.:
�
Received By: �
Date Rec'd: � ;�
YOUR E-MAIL ADDRESS ry a�u V"4.i'3a �'� � G'�� ' C ��4
77 �cCl,GSoa ��- NL
❑ OWNER �CONTRACTOR
NAME: �-8,J � S5�-
ADDRESS: % ZC GtGSDH.� CITY '
PHONE: � iA �� � a b^ I 2�
NAME: /�e� �N �'e N C�N Ce � �J . �/ L .
STATE LICENSE # p2 O �1 � � ! �
ADDRESS: Ci7 � l �� nr, (�Z n; �L� i
PHONE (O �' O' �
SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSiRUCTION
❑ ADDITION O GARAGE/SHED
O BASEMENT FINISH �ROOF
❑ DECK �� SIDiNG
❑ SW]MMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADD3TlON
❑ MAINTENANCE/REPAIR EMODEL
R� L ��
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED S1ZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
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
NUM$ER OF WII�iDOWS
AD CERT NUM
� C1TY
�_STATE M.�.�IP �S'T3 eZ
z I�1�G — �
S' STATE�_Z[P��l�
FAx � �F� s —
SIZE
STORIES
❑ WINDOWS
❑ DRA[N Tl[.E
❑ OTHER
WIDTH
p � C.� o
BASEMENT REMODELING SUBMIT:
1. Existing Fioor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION [NCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of constructian plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE ATJD
MANUFAC'TURE STICKER ON WINDOW.
ALL FE�S ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ `� b d OCCUPANCY TYPE
Permit Fee `� � $ See Back Page for Fee Schedule
Plan Review 1 $ 65% of Building Permit Fee
Fire Surcharge �,(p I$ .001 times the total job valuation
Surcharge ' d�, /$ .0005 x Permit Valuation Minimum $5.00
License Surcharge � $ -_-�, � �� $5.�0 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge —$ � Agreement necessary O Non Necessary O
Total Due � / ��I Make checks oavable to: Citv of Fridlev Attach
THIS [S AN APPLICATION FOR A PERMIT-NOT VAL(D 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 the City of ridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and work is t to start without a permit on site; that the work will be in accordance with the
approved pian in the case of all h requires vi and approval of plans.
SIGNATURE OF APPLiCANT PRINi' NAME_� �J Rp,S'SR 't �' DATE $' �� n'" I I
APPROVAL iNSPECTOR SIGNATURE