P - 48125Building
Inspections
763-572-3604
7b3-502-4977 FAX
DATE 5/ a y � i 1
SITE ADDRESS _��
THIS APPLICANT IS:
PROPERTY OWNER!
TENANT
CONTRACTOR
SUBMTT A COPY OF
YOUR STATE LICENSE
AND CERTIF'ICATE OF
INSURANCE
BUILDING
RESIDENTIAL APPLICATIUN
CIT� OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER �ON'IRACTOR
Permit No.: �` � ��� l'�G � ��
Received By:
n���
1� ubl� a► CO►�1 [as�: to
N•�E:� (�rr� 15 h O� F� 11 E N1
ann�ss: (o'a i..F-a,, Si'.5 S-�" NC crrY Fri l sTaT�N�% zrn
PHO�: (r, 1 a - � � b -'-I °I �.. o
STATE LICENSE #� O O� � S�D Z..O LEAD CERT NUMBER
Ann�ss: 13�1 t 9 F-e N wav i31vd '� ��3cr�r N
PHONE :D� ( - �ial � " �'F I I}� FAX G1S I �
PROPERTY TYPE ,�.�INGLE FAMILY/NEW CONSTRUCTION S1ZE
❑ TWO FAMILYlNEW CONSTRUCTION STORIES
PERMTT TYPE ❑ �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OF ❑ DRAIN TII.E
❑ DECK ❑ SIDING ❑ OTHER
❑ S WIMMING POUL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDTITON
�CMAINTENANCE/REPAIl2� ..1- T3 ❑ REMODELING
DESCRIBE WORK BEING DONE:
ROOFING
NLiMBER OF SQUARES �_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
--�-
OUSE ONLY
❑ OUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
WIDTH
�
��
�
raT�Ub1/ zir�,g��'
ai
F'I'
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of stntctucal members to be used
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyi p�g�t �DDTI'IONS. 8c PORCHES SUBMIT:
0���� � 1,� 1. Site Plan/Survey showing the existing structure.s
❑ O[�r ❑ Fascia and proposed pmject.
2. Two sets of constiuction plans
WINDOWS 3. F�ergy Catculations
IN EXIS'ITNG OPENINGS ❑Yes �No LOCA'ITON OF WINDOWS FOR WIND(?WS — PROVIDE U-VALUE AND
OR FOR NEW OPEIVINGS-DESCRIBE SIZE OF MANiJFACT[JRE STICKER ON WINDOW.
OPENING CFIANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�� �(�SING THE 1997 U.B.0 FEE SCHEDULE)
PnTAi. _i[)R VAi.iiATit1N P �0� � [N"f iTPANC'V 'I'YPTi,
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$ � —
$
$
$
$
$
$
$
See B�ck Page for Fee Schedule
65% of Building Pernrit Fee
.001 tit�s the total jab valuation
_OOQS x Pernut Valuation Minimum 55.00
�5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservarion Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary { )
Make checks navs�ble to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMTI'-NOT VALID UNTIL, PROCESSED
I hereby apply for a building permit and I�knowledge that the information above is complete azrd a.ccurate; that the work will be in
co�orn�a�e with the oxdinances and codes of the City of Fridley a� with the Minnesota Construction Codes; that I understand this is nat a
pernut but only an application for a pernut a� work is �t to 'thout a pemut on site; that tt�e work will be in accordance with the
approved plan in the case of wor hich requires revie an a pro of plans. i C
SIGNATURE OF APPLICANT AME K,Q,1•�'�'� � NN6hS DATE +� �� I�
APPROVAL INSPECTOR SIGNA