P - 39850Building
Inspections
763-572-3604
763-502-4977 FAX
DATF_�,J_.__C� - � �
SiTE ADDRESS ._��_
TFIIS APPLICANT (S:
PROPERTY OWNER/
TENANT
CONTRACTOR
StIBMIT A COPY OP
YOUR STATE LICE,NSE
AND CF,RTIFICATB OF
INSLJRANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
� BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
FFFECTIVE 1-I-2011 -
Permit No
Received By
D�te Rec'd:
—�— YOUR E-MAII, ADDRESS C1.��0(��.SC�-il�� . L���'j
)fi�i'@ �..C�,IS£. �YZ, �''t� �
❑ OWN��R �ONTRACTOR
NAME:: ���r1� � ��a�;
ADDRESS: Y�D �
PI10NF:: 1 �.� -� � I - ��
CI"lY i�r"! ��
NAMF r���:� ������ �s r�y 5��t —
STATE L1CF.:NSE # o2L'�j���c� � S L,GAD CF,RT NUMBFR �
ADDRBSS: I U�__�� ��r!� ,(�. �j{1'! "�� � CITY I�IC� ' If
PHONE ?(� �� JS "�S�Z ZY� FAX %-.3 -�cj�.S^ -
L�SI�IGLti PAM1L,y�1FW CONSTRUC"IION SI'.7.,k:
O TWO FAMILY/NF,W CONS"rRUCTION S'1'ORIBS
❑ ADDI'1'ION ❑ GARAGF/SHED ❑ WINDOWS
� BASEMF•.NT FINISH �ROOF ❑ DRAfN TfLF..
❑ DF:CK ❑ SIDING ❑ OTNER
❑ SWIMMING POOI
❑ NEW HOME CONSTRUCTION
� MAINTENANCE/REPAIR
DESCRISE WORK BEING DONE: '�.Q,y` ��--�- -
SIZ.E OF IMPROVEMENT
ROOFiNG /
NUMBER OF SQUARF.S S� - -S
GARACF.S
PROPOSED SIZE:
PRQPOSED HF.IGHT
SIDING
O Vinyl
O Aluminum
❑ Other
❑ HOUSI: ONLY
❑ HOUSE & GARAGE
Q ADDIlION
❑ REMODEL[NG
Gi�/'�In i l ✓ �.
❑ATTACFiEDGARAGE ��
❑ DETnCFIGD GARAC�
��
❑Softit � �'
❑ Trim (� ��
❑ Fascia � \� �'
HI31GH"i
s rA r� r�ti! rit�_._' S`i3 ?
/y(��1
L
TATE ,'' I/VZi P S J�,
�. T.
L Existing Fioor Ptan
2. Prarosed Floor plan
3 l,ist of siructurai members to be used
NEW CONS'TRUC'CION INCLUDWG DECKS,
!. Site PianlSurvcy showing the exisling structures
and proposed �mject.
\ 2 1'wo sets of constniction plans
WINDOWS \ 3. Giergy Calculations
IN EXISTING OPEN(NGS ❑Yes ❑No I..00ATION OI� WINDOWS OR WINDOWS - PROVIDE: U-VAIUE AND
OR POR NEW OPENINGS-DF.SCRIBE SIZ.E OF MANUPACTURf.i SIICKC:R ON WINDOW.
OPENING CHANGES & — �
TYPE OF W{NDOW TO BE INSTALLED N11M66R OF WINDOWS
ALL FEES ARE SASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATIOI�I $ .S^�t� =`� OCCUPANCY TYPE
Permit Fee $ , See Back Pa�e for Fee Schedule
Plan Review $ c 65%of Building Permit Fee
Fire Surcharge $ � .001 times the total job valuation
Surcharge $ � .0005 x Permit Valuation Minimum $5.00
License Surcharge $ ��� $5.00 (State Licensed Residential Contractors)
SAC Charge $ �v _ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 fr= ft x$2S= $
Erosion Control $ $450 Conservation Plan Review ^
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
TotaF Due $ `� � Make checks�yable to: City of Fridle.y Attach Stipulations
THIS IS AN APPLICATION FQR A PERMIT-NO"I� VALID l)NTIL, PROCESSF.:D
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 Fridiey and with the Minnesota Construction Codes; that [ understand 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 all work which requires review and approval of plans.
SIGNA7'URE OF APPLICANT PRIN"f NAMG DATF
APPROVAL INSPECTOR SIGNATURE - �
' PLEASENOTE: SEPATtATEPERMITSARER�:ntiiR�.T�Fnttt�T:rt�tuTnrr, G►�r�t�urrer e�m�xcrun;.,,nA� .�ar.n�