P - 37425Building
Inspections
763-572-3604
763-502-4977 FAX
. �
�.
� �� . r � r . ,:
� ' 1
EFFECTIVE 7-1-2010
i 9q ��
Permit No.: •�,� -(� � ) _
�
Received By:
DATE �T�� %� YOUR E-MAIL ADDRESS
si� aDDxESS '7�.3SU %�..e�yt�`^y' �c�. �C/.E
THIS APPLICANT IS: ❑ OWNER I��'CON1'RACTOR �
PROPEiiTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
P�RMIT TYkE
TYPE OF WORK:
rra.ME: i� aa��.o w Co r�c�
STATE LICENSE # o� � I CU 3�'L q�
C•1
� SINGLE FAMII,Y/NEW CONSTRUCTION
❑ TWO FAMII,Y/NEW CONSTRUCTION
❑ BASEMENT FINLSH ❑ ROOF
❑ DECK ❑ SIDING
_ _ _ -- ---..
❑ SWTMM
C7 NEW HOME CONSTRUCTION
fd MAINTENANCE/REPAIIt
crrY�1r�'/� sTa1�_�zir .lSS/.3 a
EXP DATE 3 — —'j I "' ' �
_ci� a ci sTa���n �1 z� 5� ! i�
�o5d qo5 i`7�45
SIZE
STORIES
�✓sr�r� � wrrmows
❑ DRAIN TILE
J�OTi�R
NG POOL
❑ ADDTTION
❑ REMODELING
DESCRIBE WORKBEINGDONE: �C� p j�q.�'���- �n�`OhKly��-
SIZE OF Il�PROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT�
GARAGES 1. Eacisting Floor Plan
❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED S12E: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HETGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITTONS. & PORCHES SLTBMTT�
❑ Trim 1. Site Ptan/Survey showing the e�cisting structures
❑ Fascia and proposed projec�
WrND��,�,s 2. Two sets of construchon plan�
IN EXISTING OPENINGS �Yes �No LOCAT'ION OF WINDOWS 3. Energy Calculations
OR FOR NEW OPENiNGS-DESCRIBB SIZE OF FOR WINDpWS — PROVIDE U-VALUE AND
OPENING CHANGES &
MANUFAC'TITRE STTCKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(] ( SING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $'"l 1�� OCCUPANCY TYPF
� Permit Fee -
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Contral
Park Fee
Sewer Main Charge
Total Due
$
$ •/�
$ �'j
$
$
$
$
$
$
$ . � �-'
See B»ck Page for Fee Sche3ule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2100 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pa able to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED
_= I�►ere-li �-appty fqr a_�i.�ul-rl�ng_pem��t a��- __a� -ot�ledge that the information above is complete and accurate; that 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 fo p ' and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of ai ' s review and approval of pl �J,/�
SIGNATURE OF APPLICANT PRINT NAME ;�/�>/r� �JC��i� DATE �,J �// (
APPROVAL INSPECTOR Si['rN F � ,