P - 39979Building
Inspections
763-572-3604
763-502-4977 FAX
DATE C� � �'
SITE ADDRESS IY 7
THIS APPLICANT IS:
��
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-201I
YOUR E-MAl DDRESS
. 1� o/t � b.c �n a c,
❑ OWNLR
o d r�s � �
PROPERTY OWNER/ NAM� n n S
TENANT ADDRESS: �� 1� / V- � Q �.I � CITY
PF�oN�: 7 t 3� S 7!- 9 3 3 S'
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICAT� OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NAME Pella Windows & Doors
sTATr , 15300 25th Ave N. Ste 100
A�nRC� Plymouth, MN 55447
PHONE Lic # 20165884 Ph. 763/745-1400
$SRJGLE FAMILY/NEW CONSTRUCTION
❑ TWO �AMILY/NEW CONSTRUCTION
❑ AUDITION ❑ GARAGG/SHGD
❑ BASEMENT FINISH ❑ ROOF
� DECK ❑ SIDING
❑ NEW HOMC CONSTRUCTION
'B,MAINTENANCE/REPAIR
DESCRiBE WORK BEtNG DONE:� W! i�i LI�OW J�l .T.0
SIZE OF IMPROVEMCNT _ LENC
Pernlit No�
Received 13y:_ ___
,
Date Rec'd:
�r� on,r s, !'o M
ATU '/`1Z1P S S�I.3�
od, - �s��3vs • � oy �
GAU CERT NC�M[3ER ��% ' i V� G d' d
C1TY STAT� 71P
FAX _ _ _
STORILS
WINDOWS
❑ DRAIN TILE
❑ OTHGR
❑ SW1MMiNG POOL
❑ ADD4TION
❑ RLMODELING
ROOF[NG ❑ HOUSE ONLY
NUMI3ER OF SQUARES _____ .__ ❑ FIOUSE & GARAGF:
GARAGES ❑ ATTACI lED GARAGE
PROPOSED SI7..G: ❑ D�TACI ILD GARAGE
PRCJPOSEll HEIG{i"i:
51DING
❑ Vinyl ❑Sofiit
❑ Aluminum O Trim
❑ Other ❑ f•ascia
WINDOWS
IN EXISTING OPENINGS �Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGGS & p S� �,n �S
TvnF nF wn�nnw Tn RF. 1NSTALLED � NUMBER OF WINDOWS
//1 /�''iS7�rnd �6�71i/��'r
WiDTH HEIGHT SQ FT
�
l3/�SGMENT RfM017GLING SU�MI'1':
I . Existing Floor Plan
2. Proposed Iloor plan
3. List of structural members to be used
POR NEW CONSTRUCTION INCLUDINCi DI:CfiS,
ADll1T10NS. & i'ORCHES SUC3MIT:
^ I. Site Plan/Survey showing tlie existing structures
and proposed project.
2. Two sets oY construction plans
3. Energy Calculations
FOR WfNDOWS — PROVIDG 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 � � O O� 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
$ �'f ,j, ��j See Back Page tor ree 5chedule
$ 65% of Building Pennit Fee
$ S. � o .001'times the total job valuation
$ � v O .0005 x Permit Valuation Minimum $5.00
$ $. 0 O $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determ+ned by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ /'7 p, ,? Make checks payable to: City of Fridley Attach Stipulations
Tl-IIS IS AN APPL1CATlON FOR A PERMIT-NOT VALID UNT1L PROCESSED
( hereby apply for a building permit and 1 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 Fridley and with the Minnesota Construction Codes; that 1 understand Chis is not a
permit but only an application for a per it and � ror c►s not to start without a permit on site; that the work will be in accordance with the
a roved lan in the case of all w re ui s view and a roval of la.n.� < �( /
Sp NATURE OF APPLICAN � q PR NT NAME p!/ M ✓� f���� DAi'E � �� `` //
APPROVAL INSPECTOR SI NATURE
nr '� n e� �rivr�� c�ne�z e�'F TC RF.'RF.ni ]TRF.T) FnR PLUMBIN(Cr. ELECTRICAL AN.D MECHANICAL WORK