P - 45819Building
Inspections
763-572-3604
763-502-4977 FAX
�A rE_ � - , � _
SITE ADDRtiSS �
TIIiS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
F,FFECTNE 1-1-2011
tJ OWNtiK
PROPERTY OWNER/ I NAME: �
TENANT ADDRESS:
YOUR E-MAIL ADDRESS ('(��" E.� l._ �'J j'�
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�CONTRACTOR
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Permit No.: �-v I V
Received By:
- Date Re�`�C� � , �j'�
�-�,��l��' � CflYy� -
STATE�Z[P S_��
CONTRACTOR NarvtE' VI c�t,�.ti C�1�+e�' i 0/S hk S� /-� .1��' -
� SUE3MIT A COPY OF y �
YOUR STATE LICENSE STATE LICENSE #��,1��1 �j'3 !-� LEAD CERT NL�MBER
�� AND CERTIFICATE OF ADDRESS: � U ��j �� �F �� �v, �(,7)'� � CtTY�� � ��I�F STATE/��NLIP .� S �
INSURANCE pF{UNE (,�, -3 )S `�`� fl � FAX t�� - I S-��t C� �
� PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILY/NEW CONSTRUCTION STORIES
PER1VIlT T'YPE L7 ADDITION ❑ GARAGE/SHF,D �7 WINDOWS
❑ BASEMENT FIMSH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SID[NG ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONS TION O ADDITION
, �MAiNTENANC EPAI ❑ REMOD[:LING
i DF.SCRIF3E WORK BEING DONF,: "1�,�'L Q{-5- -����j 7
�' SIZ,E OF IMPROVEMENT LGNGTFI WIDTH HEiGH"T SQ FT
� ROOFING Q ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT
NUMBER OP SQUARES �! �HOUSE & C�P6'�; ���� �. �xisting Floor Plan
I GARAGF,S ❑ ATTACHED GARAGE 2. Proposed floor plan
�PRnPOSFD SI7E: D DETACHED GARAGE 3. List of structural members to be used
PROPOSFD HEIGHT:
I SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADD[TIONS. & PORCHES SUBMIT:
I❑ Almninum ❑ Trim 1. Site Plan/Survey showing the existing structures
� O(hher ❑ Fascia and proposed project.
II WINDOWS 2 Two sets of construction plans
3. Energy Calculations
�IIN EXIST1riG OPET�iINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIUE U-VALUE AND
OR FOR NEW OPENINGS-DESCKIBE SIZE OF MANUFACTURE STICKEK ON WINDOW.
OPENING CHANGES &
TYPE OF W[NDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�i ( ING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 11 OCCUPANCY TYPE
Pe►r?it Fge � See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surchar�e $ .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 $ g� Agreement necessary O Non Necessary O
Total Due $ "! Make checks pavable to: Citv of Fridlev Attach Sti
THIS
I hereby apply for a building permit an
conformance with the ordinances d
permit but only an appiication e
approved plan in the case of
SIGNATlJRE OF APPLICANT
APPROVAL INSPECTOR SIGNATUR
PLEASE NOTE: SEPA TE PE]
,�
��
lations
N APPL[CAT10N FOR A PERMIT-NOT VALID UNTIL PROCESSED
knowledge that the information above is complete and accurate; that the work will be in
f t City Fridley and with the Minnesota Construction Codes; that 1 understand this is not a
and rk s not to start without a pe on site; that the work will be in accordance with the
'res ew and approval of plans. '� / �
PRINT NAME ��L, /�-�s DATE � r/� � j�