P - 39332Building
Inspections
763-572-3604
763-502-4977 FAX
I DATE �' I � ` �
SITE ADDRESS 5�5��
THIS APPL[CANT IS:
PROPERTY OWNER/ NpME:
TENANT ____
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATB OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-I-2011
YOUR E-MAIL ADDFtESS ��22����
_ /1�.�.. �"� � d��e� �N ��y.� r
OWNER ❑CONT TOR
�ae;��m� � J�ar�'� e� �,.�`, 5
;s: 53� _S'�-'�' ��; �.;�F_. crTV Fi�, 1e�!
PHONE: 7�-, `'� " vZoC9 °� r'/ r�C
STATE LICENSE #
CERT NLJMBER
ADDRESS: CITY_
PHONE FAX
ING EW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES�_
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK SIDING ❑ OTHER
❑ SWIMM[NG POOL
❑ NEW HOME CON CTION ❑ ADDITION
j�MAINTENANCE EPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF [MPROVEMENT
ROOFING �-7 �
NUMBER OF SQUARES i'/, �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
�HOUSE ONLY
HOUSE & GARAGE
❑ ATTACHED GARAGE
� DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
1�.�Il��i�l
Permit No.: U�' ��'� � C�7 �
Received By: ` "`'�
D���'� � P 1 3 2011
ATE�ZIP �S�
ATE ZfP
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS, & PORCHES SUBMIT:
(. Site PIan/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 $ OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ 2 .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $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 $ �Q��— Make checks payable to: City of Fridley Attach Sti
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D 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 Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a ermit 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 wor 'ch req ir r�ew and approval of plansf_
SIGNATURE OF APPLICANT PRINT NAME C�p('P,(111� �� �u-► S DATE 9-13 �I'
APPROVAL INSPECTOR SIGNATURE