P - 45378Building
Inspections
763-572-3604
763-502-4977 FAX
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
❑ OWNER
Permit
Received By:
CITY OF FRIDLEY I vate xec'd: �
EFFECTNE 1-1-2011
YOUR E-MAIL ADDRESS � �G���L�I/�C6��� �( I •�C'> /%��
e / r_
ADDRESS: �l��P S'�=' S� �E ci�.
PHONE: 7G> . S^%t.f - �!T%
STATE LICENSE
❑ SINGLE FAMII,Y/NEW CONSTRUCTIi
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMM
ATE -l't "�ZIP-1�-�-4-
CERT NUMBER
CITY P���� STATE�ZIP r�Z�
FAX llo S --
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: � r` 1n r�.,+Si � oi -�-�/1 y S�
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES �� �HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑Soffit
❑ Trim
❑ Fascia
BASEMENT REMODELING SUBNIIT:
1. Eacisring Floor Plan
2. Proposed floor plan
3. List of suuctural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS, & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing siructures
and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calcularions
IN EXISTING OPENINGS ❑Yes ❑No LOCAT'ION 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 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 $ OCCUPANCY TYPE
Permit Fee $ , See Back Page for Fee 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 () Non Necessary ()
Total Due $/07 . _ Make checks payable to: City of Fridley Attach Stipulations
THIS IS AN APPLICATION FOR A PERNIIT-NOT VALID UNTILPROCESSED
I hereby apply for a building permit and I acknowledge that the informarion • above is complete and accurate; that the work will be in
conformance with the ordinan and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicat n or a pernut 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 f a ork which requires review and approval of plans.
SIGNATURE OF APPLICANT RINT NAME �� ^^`/�_DATE�%�(
APPROVAL INSPECTOR SIGN
/20� Sq,.��-�� 1ro,�3v