P - 36668Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � ^ �J �
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-20] 1
❑ OWNER
NAME: _ 1 �
� �i�/� % �
NAME:�i [�1 I
STATE LICENSE #
E-MAIL ADD, RESS �PYa►� /�.C�S r^'f�
/� N�
CRl�i�
_LEAD CERT NUMBEI
NZ- CITY
PHONE 76 3� S b t� �(���� , FAX %�
❑ SINGLE FAMILYMEW CONSTRUCTION SIZE
❑ TWO FAMILYMEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK �SIDING ' s!F ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�TMAINTENANCE/REPAIR . ❑ REMODEC,MG
DESCRIBE WORK BEING DONE
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
�Aluminum — � ? p �
❑ Other
wCr WOO
❑ HOLTSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES 8c
(.t
Permit No.: ` ` � 4"
Received By:
Dat�' '�
_ w�J • �.�t
�
'ATE �.tzlP
' "—`f / (�T l "' /
STATEM.wJ ZIP,S`��
FT
BASEMENT REMODELING SUBM[T:
I. Existing Fioor Plan
2. Proposed floor plan
3. List of structural members to be used
\ FOR NEW CONSTRUCTION RJCLUDING DECKS,
�` n ADDITIONS. & PORCHES SUBMIT:
��t 1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two seu of construction pians
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF WiNDOW TO BE INSTALLED NUMBER OF WiNDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USI THE�j7 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �•--' OCCUPANCY TYPE
Permit Fee $ (n3, See Back Page for Fee Schedule
P1an 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 () Non Necessary ()
Total Due $ ''� n, n Make checks uavable to: Citv of Fridlev Attach
THIS 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 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 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 of all wor 'c re uires review and approval of plans
SIGNATURE OF APPLICANT _ PRMT NAME� C2�J � 1 � DATE �" ,,�.Jr + J/
APPROVAL iNSPECTOR SIGNATURE