P - 48529Building
Inspections
763-572-3604
763-502-4977 F
DATE � . % �!?/ /��
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SITE ADDRESS �zJ
THIS APPLICANT [S:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-I-2011
YOUR E-MAIL ADDRESS
❑ OWNER / 'ONTRACTOR
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' PROPERTY OWNER/ NqME:__�,��17n��r� '
��� TENANT ADDRESS: �G�'I � Il ��� ��;. /��_CITY
PHONE: �� f� � �� '— !� %
CONTRACTOR '
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NAME: � I��4 � J����G/ �L
STATE LICENSE # ? �_
ADDRESS: ���% � �I � � �L,�G�
PHONE — _lDI � — 'ZJ!%% _' �j ��-�
�INGLE FAMILY/� C.'O�dsT-�'ii�C�'1�ON
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDfTION
❑ MAINTENANCE/REPAIR �EMODEL
DESCRIBE WORK BEiNG DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES �-•
GARAGES
PROPOSED SIZE: � j %�
PROPOSED HEIGHT:M��
SIDING
❑ Vinyl
❑ Aluminum � j 3� -
❑ Other N't ��
WINDOWS
IN EXISTING OPENiNGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE S1ZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
0
LEAD CERT NUMBER
CITY ////e
Permit No.:�'(
Received ByC��
Date����a� �.,;
ec'd:
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STATE ZIP_
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FAX �/�� '
S1ZE �f.2�'l ��G�`-
STORIES � ,
❑ WINDOWS
❑ DRAIN TILE
�THER
�
LENGTH WiDTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION �NCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. 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 $� j�.,J `=�-=- OCCUPANCY TYPE
Permit Fee $ j 10��. Z� See Back Page for Fee Schedule
Plan Review $ �, I � 65% of Building Permit Fee
Fire Surcharge $ ��ST; .001 times the total job valuation
Surcharge $ ,�{ );� .0005 x Permit Valuation Minimum $5.00
��, License Surcharge $ �.,uL� $5.00 (State Licensed Residential Contractors)
' SAC Charge $ � $2230 per SAC Unit (Plans to MWCC for determination)
' Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ �i �"� ( Make checks payable to: City of Fridley Attach Stipulations
THIS IS AN APPLICAT]ON 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 C�.{�y of Fridley and with the Minnesota Construction Codes; that I understand this is not a
pennit but only an application for a permi a w�rk�� s not t start without a permit on site; that the work will be in accordance with the
approved plan in the case o� work whic r'� u�`es�ev�kw � approval of pla s. y�, � �,
SIGNATURE OF APPLICA��'"'� fr, „ F��/- -�- P 1 T NAME '/ -' �DATE :,��r /
APPROVALINSPECTORSIUAI.� � `� � �' ` � ���L---"�� �'' � ` — �- �� � ��
PLEASE NOTfi: SEPARATE PERMITS AR�,�� QU ' D OR PLUMBING, ELECTRI'CAL AND MECHANICAL WORK
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O � i9�"�lA�� ���SS���Ce Designer project mngr job no.
�: � � B. Bverson xxxx
� 521 Rice Creek Boulevard
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�rid9ey, 9UIfV 55432
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DESIGN BY MJ REMO�ELING INCOPRORATED IS PROTECTED BY iHE COPYRIGHT L4WS OF 7HE UNITED STATES OF PMERICA THIS PROTECTION MCLUDES BUT IS NOT LIMITED TO iHE OVER,4LL FORM AS WELL AS TNE ARR/WGEMENT AND COMPOSITION OF SPACES AND ELEMENTS OF THE DESIGN 2010 COPYRIGHT MJ REMODELM�