P - 45758Building
Inspections
763-572-3604
763-502-4977 FAX
DATE /O �
SITE ADDRESS C
THIS APPLICANT [S:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FR.IDLEY
EFEECTIVE I-1-2011
YOUR E-MAIL ADDftESS
)�L AC l�y :5�.
❑ OWNER l�,CONTRACTOR
Permit No.: %o� � �
Received By: f � 1'`���
������� �� ��i�
PROPERTY OWNER/ NAME: ��t✓j G� �`t,` l(�Cf
TENANT qDDRESS: Cl� gil� V �-y� (� %��` c��e
(%`'T� / CITY �i ��/�� STATE��ZIP
PHONE:
CONTRACTOR NAME: Y�%�l�"tSf'
SUBMIT A COPY OF STATE LICENSE # �(�i�`J �v a7% LEAD CERT NUMBER
YOUR STATE LICBNSE /� �!
AND CERTIFICATE OF ADDRESS: C9 "lS� SI'Ca''1 d"�- CT ` CTTY �y� ��- STATEj"I/�ZIP�
INSURANCE pHONE %� ,,�'' �cf�%'��o��— FAX
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING DOP
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES�
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
�LLSINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
❑ GARAGE/SHED
4�ROOF
❑ SIDING
❑ SWIMMII�G POOL
�� (�.P-/L�
; WINDOWS
�, IN EXISTING OPENINGS ❑Yes ONo
� OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
� TYPE OF WINDOW TO BE INSTALLED
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
❑ ADDITION
❑ REMODELING
2�(/S � i
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
Wi�
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of strucwral members to be used
FOR NEW CONSTRUCTION RJCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE 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)
TOTAL JOB VALUATION $__ �%v� _ 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
$ � 1. ��
$
$
$
$
$
$
$
$
$
$ � 0
See Back Page for Fee Schedule
65% of Building Pennit 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 pavable to: Citv of Fridlev Attach Sti
THIS IS AN APPL[CATION 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; that the work will be in
conformance with the ordinances and codes of the City of Frid]ey and with the Minnesota Construction Codes; that I undersfand this is not a
permit but only an application for a permit 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 w requires review and approvaf of plans. �� // �� �, �� fl �
SIGNATURE OF APPLICANT ` PRINT NAME /7n DATE
APPROVAL [NSPECTOR SIGNATURE