P - 40733.. ,. .
�3uilding
Inspections
763-572-3604
763-502-4977 FAX
DATE��
SITE ADDRESS �
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWIVER
PROPERTY OWNER/ NAME:�
TENANT ApDttESS:
PHONE: (
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICEI�'SE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
E-MAIL
�=
��riiioe
NAME: L-j�J U ►r .l! 11 ► { ' U�l 7�
STATE LICENSE � CI
ADDRESS. � A
PNONE ��s'h " � � �' �'1 Z �l L�
�SINGLE F.AMILI'.TEW CONSTRUCTION
❑ TWO FAMILY'/NE�i' CONSTRUCTtON
❑ ADDITIOn ❑ G.4RAGE.�SHED
❑ BASEMENT F[N1SH �ROOF
❑ DECK ❑ SIDING
❑ SV�'In4MING PO(
TYPE OF WORK: ❑ NE�t' HOME CO�'STRUCTION ❑ ADDITION
� MAINTENANCE/REPAIR ❑ REMODEL
DESCRIBE WORI: BEING DONE: '� �'�� �% i
SIZE OF IMPROVEMENT LENGTH Wlt
ROOFWG ❑ HOUSE ONLY
NUMBER OF SQUARES � �HOUSE R GARAGE
GARAGES �.ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED G.ARAGE
PROPOSED HE]GH7:
SIDING
❑ Viny]
❑ Aluminum
❑ Other
CIT1'
Permit No.: �� � � ���� � �
R
Received By: ' `
��ea��--�,-��
STATE
LEAD CERT NL'MBER N/i l" l/�' .�//. ���
i� ��1. ���CITY� Li �� t✓ STA7�E�ZIP ��
FAX ����� 7���' ��ZI
SIZE
STORIES
❑ WINDOR'S
❑ DRAIN TILE
❑ OTHER
SQ FT
BASEME?�T REMODELING SUBMIT
1 Ex�stine Floor Ptan
2 Proposed floor plan
3 List of strucmral members to be used
FOR NER" CONSTRUCTION INCLUDING DECKS.
❑Soffit ADDITIONS. 8: PORCHES SUBMIT.
❑ Trim 1 Si[e PIan�Survey sho�cine the existina svuctures
❑ Fascia and proposed project
2 T��o sets of construcuon plans
WINDOWS 3. Enercr Calculations
IN EXISTING OPENINGS ❑Yes ONo LOG4TlON OF �1'INDO�'S FOR WINDOVdS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOIk'.
OPENING CHANGES &
7'YPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOVi'S
ALL FEES ARE BASED ON �'ALL�.4TION, INCLUDING THE COST OF LABOR AND MATERIALS:
-7 'G THE 1997 ti.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ I�� OCCUPANCY T1'PE
Permit Fee $ - 5 See Back Page for fiee Schedule
Plan Review $ 6�% of Building Permit Fee
Fire Surcharge $ ' �� .001 times the total job valuation
Surcharge _$ �+� .0005 x Permit Valuation Minimum $5.00
License Surcharge � a�— $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= i
Erosion Control $ �450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ .��p, ¢,L�� Agreement necessary O Non Necessary O
Total Due $ ►1)y, , 1)'/j Make checks navable to: Ciri of Fridlev Attach Stinulations
TH1S IS AN APPLICATiON FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is compiete 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 r pe ' nd is not to start without a permit on site; that the work will be in accordance with the
approved plan in the c wh' iew and approval of pl �_��_�'
SIGNATUItE OF APPLICANT PRINT NAME �`�✓I_� �� DATE
eDOOnc,., ,�,� ............. ... .
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, BLECTRICAL AND MECHANICAL WORK