P - 35766Building
Inspections
763-572-3604
763-502-4977 FAX
DATE- U ��
SITE ADDRESS �7
THIS APPLICANT IS:
' �l%!
�/�.. 'i'L
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFEECTIVE 1-1-2011
_ YOUR E-MAIL ADDRESS �OlSOlt-�G/t°d
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❑ OWNER ■CONTRACTOR
NAME: % %-G. .S4 `I/Q..'fiGtt Q� /�Ns.J/
ADDRESS:_ � , CITY
PHONE:
NAME: G/P�QI" G�O iG� �Q.f�PeC��G�L
PermitNo.:�( � �
Received By:
Date I�� � � � (L� � � �
e C rC,f7L/'�t7�,as2� Go .n
;,s-ya 1
STATE ZIP
STATE LICENSE # a���.3Sf.JrB LEAD CERT NUMBER_ /y'�T /o� 3�3 "' I
ADDRESS:��'! i%K.b�-SS� ��l.f �/"/VQ CITY �aS"�..°V �� STATE�IP S/�3
PHONE `S/ �6��%%O FAX �/"�77' �y��
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILYMEW CONSTRUCTION STORIES
PERMIT TYPE ❑��rTioN ❑ GARAGE/SHED Q WINDOWS
❑ BASEMENT FINISH ■ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK:
❑ NEW HOME CONSTRUCTION
r MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE:
r - �-
SIZE OF [MPROVEMENT
ROOFIIVG �
NUMBER OF SQUARES _�
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
O Other
WINDOWS
IN EXISTING OPENINGS '❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WMDOW TO BE MSTALLED
.--
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
�Soffit
❑ Trim
� Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
HEIGHT
FT
BASEMENT REMODEL[NG SUBMIT:
I . Existing Eloor Plan
2. Proposed floor plan
3. List of structurai members to be used
FOR NEW CONSTRUCTION fNCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. 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 $ OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job va(uation
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 $ , Make checks aavable to: Citv of Fridlev Attach Stioulations
THIS IS AN APPLICATION 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 Fridley and with the Minnesota Construction Codes; that I 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 �.i.ch • �res review and approval of plans �/
SIGNATURE OF APPLICANT =��-'C_._ PR1NT NAME j,��CliG �S(J�'� DATE ��' !^ 2��I
APPROVAL INSPECTOR SIGNATURE