P - 60314�
< v +
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE c, ' �C.Q -��
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
�rYrE oF woxx:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDI,EY
EFFECTYVE 1-1-2011
YOUR E-MAIL ADDRESS
�- • .[ ii�.�7
PHONE: 71? �J - �C�� " ! /JS
STATE LICENSE #
ADDRESS� �1 7
0
PHONE L!� ! - /�f'� % o�C.? 'r(Q
�INGLE FAMII.
TWO FAMILY/NEW CONSTRUCTION
� ADDITION 0 GARAG
O BASEMENT FII�IISH ❑ ROOF
❑ DECK {7 SIDING
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
LEAD CERT NUMBEP
CI1'Y �l
FAX
s�
STORIES
JSHED OWS
❑ RAIN TILE
O OTHER
NG POOL
❑ ADDITION
O REMODELING
�� �: /�� � '
� - q � ��'�'�'
► �
. . -, : � ��i
� . :+�' - •�i. � ' ' 1 � �!�'
A
'�� DESCRIBE WORK BEING DONE:� Q(�p�/,�'�- /�( )�Cd x',l�C.� .�)�') �if!'Z,f�`/�(,�-i� (�,�-�
I SIZE OF IMPROVEMENT LENGTH WIDTH HEIGI3T
�i, ROOFING ❑ HOUSE ONLY
! NUMBER OF SQUARES ❑ HOUSE & GARAGE $ASEMENT REMODELIf
1. Existing Floor P]
' GARAGES O ATTACHED GARAGE 2. Hroposed floor p
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural
I PROPOSED HEIGHT:
I SID1NG FOR NEW CONSTRUCTII
ADDITIONS. & PORCHE:
I❑ Vinyl OSoffit 1. Snte Plan/Survey
O Aluminum O Trim and proposed pn
O Other O Fascia 2. Two sets of wns
WINDOWS , 3. Energy Calculati
IN EXISTiNG OPININGS �es ONo LOC}1TI.ON OF WINDOWS FOR WINDOWS - PRO�JI
OR FOR NEW OPENINGS- SCRIBE $IZE OF ��Ci�� (,8'X'j �/� [T237YVL� MANUFACTURE STICKE
OPENING CHANGES & ,�,,j /,,/'�
TYPE OF WINDOW TO BE INST LED �"�U-f S( LUxI� NUMBER OF WINDOWS
ALL FEES ARE B.�SED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIAI
TOTAL JOB VALUATION S'�/ �S � THE 1997 U.B.0 FEE SC OCCUPANCY TYPE
Permit Fee $ �� "L5 See Back Page for Fee Schedule
Plan Review $ 65% of Bailding Permit Fee
Fire Surchazge $ Z L .001 times the total job valuation
�
Surchazge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ S'0 $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determinatio
Curb Cut Escrow $ ft+ 6 ft= ft x$24 =$
Erosion Control $ $450 Conservation Plan Review
Pazk Fee $ Fee D.etermined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Totsl Dne $ :� Make checks navable to: Citv of Frtdlev Att
AT'F..�7.IP : ,�d�
SQ FT
SUBMIT:
mbers to be used
INCLUDING DECKS,
i�t�he existing structures
t.
:tion plans
U-YALLTE ANT.1
)N WINDOW.
THIS IS AN APPLICATION 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; th�at the work will be in
conformance with the ordinances and codes of 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 is not to start without a permit on site; that the work will be�in accordance with the
approved plan in the case of a�l work w'ch re es re iew and approval of plans.
SIGi�iAT[3RE OF AFPLICANT ��I',j /I . _ i _ PR1NT NAME 1�,-� � Gin,� � D�� � � - �