P - 46713Building
Inspections
763-572-3604
763-502-4977 FAX
DATETI�[y[__
SITE ADDRESS I� IiJ�
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
I CONTRACTOR
SUBMIT A COPY OF
I YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING DO
i SIZE OF IMPROVEMENT
ROOFING
' NUMBER OF SQUARES�- �
', GARAGES
i PROPOSED SIZE:
' PROPOSED HEIGHT:
SIDING
O Vinyl
❑ Aluminum
❑ Other
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
YOUR E-MAIL ADD}tESS
_ �71-2�3
Permit No.:
� - - � : �%..
1 i.1. � .' , `
` � it.s►�.cc
CITY�y'��(I �^t^n STATF�J�ZIP ��,5, y-��
NAME: �I�S %� L.-pv���'�,,:5 .,��,��,- i�rs,�1,L
STATE LICENSE #_I�C G�I C� I% LEAD CERT NUMBER
ADDRESS: 33�9� •i�,,,, � S C,�., C�] n�_,�I , CITY �� � STAT�1/V ZIP��"l�
PHO�1E Z. - 5 3 Z- 2� �� F,,�{
GLE FAMILY/NEW CONSTRUCTION SIZE �.�
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION � G�RAGE/SHED ❑ WINDOWS
❑ BASEMENT FIN[SH IC�OF ❑ DRATN TILE
❑ DECK ❑ SIDING � OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WiNDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
OF
HEIGHT
BASEMENT REMODELMG SUBMIT:
I . Existing Floor Plan
2. Proposed floor pCan
3. List of structural members to be used
Oo
FOR NEW CONSTRUCTION tNCLUDING 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 ANQ
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 $ �J 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 O Non Necessary O
Total Due $ �%5��— Make checks pavable to: Citv of Fridlev Attach Stipu
lations
THIS IS AN APPLICATION FOR A PERIvtIT-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 pe 't 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 w, quires review and approval of planss � )
SIGNATURE OF APPLICANT PR1NT NAME /-�e.A /G.�„� 1 h DATE ��/ rI �
APPROVAL INSPECTOR SIGNA RE