P - 48128Building
Inspections
763-572-3604
- 763-502-4977 FAX
DATE S '( ('`I
' (SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
' I SIZE OF
ROOFING
' NUMBER OF SQUARES _
' GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-I-2011
YOUR E-MAIL ADDRESS
� � ��
❑ OWNER L�ONTRACTOR
NAME:
ADDRESS:`-t�Pl� c7 Q � � CITY
PHONE7� 3 �7d — � ! � �
NAME: J..�/L.�YV� � '
'/ G f
STATE LICENSE # n l� 7 O n LEAD CERT
, �..r _� ..
PHONE �S�"' %8�� aG�"{Go FAX �.S �� %
�F'SINGLE FAMILY SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
� ADDITION ❑ GARAGElSHED INDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION 0 ADDITION
;�.MAINTENANCE/REPAIR ❑ REMODELING
. 1. . n 9�[lil0 1 L lA � — IAi�
LENGTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
oso�t a _+�p��
❑ Trim a� �
❑ Fascia �1�
a-
HEIGHT
(o �
Permit No.: ���?�� y
Received By: �
Date�el: l7� � . �� ��-�J
TA'
�STATE//N ZIP.
S d
BASEMENT REMODELING SUBMIT:
i. Existing Floor Plan
2 Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site PlanlSurvey showing the existing structures
and proposed project.
2. Two sets of construction plans
VyINDpWg � „ .ri-w ,. �.��u„(-�(', 3. Energy Calculations
�y��s�i�.....� - \
IN EXISTING OPENINGS Yes ❑No CATION OF �Np O�W��S� /' � FOR WINDOWS — PROVIDE U-VALUE AND
OR F�R NEW OPEidiYdGS-DESCRIBE S}�E OF ��[rn's.�aYh VU'�"'�'� —'T'� MANUFACTUIZE STICKETZ ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED �� NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ Lo OL� •� OCCUPANCY TYPE
Permit Fee $ '�, 3% a. See Back Page for Fee Schedule
Plan Review $ 65% of Building Petmit 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 Chazge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$24 =$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Dae $ o• Make checks payable to: C#ty of Fridley Attach Stipnlatfons
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL PROCESSED
I hereby apply for a building permit and I acknowled e that the information above is complete and accurate; that the work will be in
conformance with the ordinance d codes of the City ridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatio for permit wor ' ot to start without a permit on si e• that the work will be in accordance with the
approved plan in the case of 11 wo which r ire d ap roval of pl s. /r�
SIGNATURE OF APPLICANT T NAME / _DATE �' ` ` . �/