P - 44527Building BUILDING Permit No.:���( �_ ���
Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604 CITY OF FRIDLEY Date Rec'd:
763-502-4977 FAX ����--��
EFFECTIVE 1-1-2011
DATE � � '- ��� YOUR E-MAIL ADDRESS �� �/,/'f�(% �1����,5� C� �(j/,riJ�"� ��.�`'
S[TE ADDRESS �/ ✓ /1'//7`�� ,�57���L'-f
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
❑ OWNER �CONTRACTOR
NAME: l�dlY 5�'/'�e/J/'� „�G%,�/C�OL' ��
ADDRESS: CITY
PHONE: �d/oZ - O �D "� ��� �
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A
STATE LICENSE # �� 5' 'y"% �p[ ["J LEAD CERT NUMBER
ADDRESS:���,fi !'i/GG-c?�e�GQ ��j'/T/GtJ CITY ��'arr%G�� STATF/t�/LIP 3�'3a�'
PHONE �% �' �6 ? /O� %� FAX �
❑ SINGLE FAMILY/NEW CONSTRUCTION S[ZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK�JJEW HOME CONSTRUCTION
r�[�MAINTENANCEIREPAIR
DESCRIBE WORK BEING DONE:
SIZE OF [MPROVEMENT '
ROOFING i
NUMBER OF SQUARES
GARAGES '
PROPOSED SIZE: '
PROPOSED HEIGHT: '
SIDING '
❑ Vinyl I
� Aluminum
Q Other ,
WINDOWS
IN EXISTING OPENINGS ❑'
OR FOR NEW OPENINGS-DE
OPENING CHANGES &
TYPE OF WINDOW TO BE Ir
ALL FEES ARE
TOTAL JOB VALUATIOP
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
❑ ROOF ❑ DRAIN TILE
❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION � ,�
❑ REMODELING (U �/v
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
�No LOCATION OF WINDOWS
tIBE SIZE OF
ALLED_
NUMBER OF WINDOWS
7�� HEIGHT 4Z S� �, SO FT
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 seu of conswction plans
3. Energy Calculations
FOR WMDOWS - PROV[DE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
.SED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
$� �� SLT�aNG THE 1997 U.B.0 FEE SCHEDULE)
�J OCCUPANCY TYPE
$
$
$ --
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 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 vavable to: Citv of Fridlev Attach
lations
' THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a build�ng permit and I acknowledge that the informat9on above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fr'dley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatiion for a permit and wor ' not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of i 'review and approval of pla
SIGNATURE OF APPLICANT ' PRINT NAME ��►/' DATE
APPROVAL INSPECTOR SIGNA� URE T j T— `