P - 48092Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � ( � V ( l�
SITE ADDRESS _,�,,�
TH[S APPLICANT IS:
PROPERTY OWNER/
TENAIVT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MA1L ADDRESS
' � ��
❑ OWNER ❑CO TRACTOR
NAME: A�
ADDRESS: p CITY ie l�
PHONE: l� � O 6� D(� (pS
NAME: G I ` �fY i�"i �
STATE LICENSE #,z /�r(�j �(��?__ LEAD CERT NUMB�[
ADDRESS;,j S t�pFJC�'I' ��-
,� ,. , �� q
PHONE _ _
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ STDING
CITY�
f FAX G�/ —oZ�10 —
SIZE
STORIES
❑ SWIMMMG POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BE[NG DONE: e" r ��
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING /:,, ❑ HOUSE ONLY
NUMBER OF SQUARES �v O HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
❑ DRAIN TILE
� OTHER
HE[GHT
Permit No.��
Received Byi�
D��'� A��'`'` � �
STA
A'
F7'
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
����
FOR NEW CONSTRUCTlON INCLUDING DECKS,
SIDING ADDITIONS. & PORCHES SUBMIT:
❑ Vinyl ❑Soffit 1. Site Plan/Survey showing the existing structures
' ❑ Aluminum ❑ Trim
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WiNDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WMDOWS
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 $ � 5 See Back Page farFee Schedule
Plan Review $ 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 $ $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 $ Z Make checks payable to: City of Fridley Attach Stipulations
THIS [S AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and T ac at the information above is complete and accurate; that the work will be in
conformance with the or inances the City of Fri ey and with the Minnesota Cons ction Codes; that I understand this is not a
permit but only a ' ti fo a permit an start witho , a permit on s' ; th t he work will be i accordance with the
approved plan i all k which re ires review and approval of p ns.
SIGNATURE OF ICANT PRMT NAME D�ATE �
APPROVAL INSPEC T � � _ _