P - 41394Building BUILDING Perm�t Ivo.: ��.'i�� � ���' ��a��
Inspections RESIDENTIAL APPLICATION Re�ei�ed By:
763-572-3604 �� � s � � �
CITY OF FRIDLEY Date Re�� �' �- �•� �=
763-502-4977 FAX EFFECTIVE I-I-2011
�
DATE �� � ��G � �� � YOUR E-MAIL ADDRESS �� ,� .- �- c �i Y��� �/�� � f�r� ,l� lt� �,� s7
SITE ADDRESS �j� � � �, � � � �F /� �
THIS APPL,ICANT IS ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME:
TENANT ,�pRESs
PHONE: ,
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
. �� s.
�� {�� /i7..'� ' /��C- CITY J�-�;��c% `��/ STATFi�%� �" Z1P ��� ����
^ / � � �'
NAME: 1��fi�J /i..r����•-,,� �t�����,��� -� ����(.-z;, �.v�
STATE UCENSE # � GG S���S � LEAD CERT NUMBER
ADDRESS:�� ����y _� CITY �� ��� ��_ lr '
i .� �' r �� �� STATE �.1/ZIP � S �, '/-z
PHONE r 7 �•' -- y � �! - �`C�/ . � FAX �j � ���� — �� % %
�i7 SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES�
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT F1N1SH ❑ ROOF ❑ DRAIN TILE
❑ DECK �SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEiNG DONE:
SIZE OF lMPROVEMENT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED S1ZE:
PROPOSED HEIGHT:
��m�l
❑ Aluminum
❑ Other
VVINDOVI'S
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE S[ZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE [NSTALLED
/Ct ; � i ✓.^ � �, �� .> e
C WIDTH
Q HOUSE ONLY
� HOUSE & GARAGE
� ATTACHED GARAGE
❑ DETACHED GARAGE
� , �
�flSoffit .-'�r�� ;-�v,��,.��.» �i�.�r/�',
,fl
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
"cl �'�/ ;.,� �, �,�1,, Sc'����'`f � 1'°tsc,�c
HEIGHT ; � ( SQ FT
�
QASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. Lis[ of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR 1�l�INDOWS - PROVIDE U-VALUE AND
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 $�''�" ��� �, -. OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ i��'� ��_`� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �1 �i3 .001 times the total job valuation
$ '"} � �_ .0005 x Permit Valuation Minimum $5.00
$ `��:-�i $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ � �.� ;;�� � Make checks payable to: City of Fridlev Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
1 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
pennit but only an application for a permit 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 ofall work which requires review and approval of plans. �
S]G?JATURE OF APPLICANT :� � � _ PR1NT NAME - " �. � „ � DATE '� � �' ,'�,(/
APPROVAL INSPECTOR SIGI�'ATLRE � � � � �
PLEASENOTE:' SEPARATE PERMITS AKE REQUIRED FOR PLUNfBING, ELECTRiCAL AND MECHANICAL WORK