P - 45764Building
Inspections
763-572-3604
763-502-4977 FAX
DATE j/r� / ,�
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SITE ADDRESS _
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-201I
z�6 �OUR E-MA]L ADDRESS
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❑ OWNER _ �ONTRACTOR
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NAME: f%ry1 (✓ G. �LS_.S ��"P
ADDRES : � G'� '� '�C Q �- ��CITY,
PHON��� � , „�� ��` � 7 GJ �
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Permit No.:
Received By: !� (,
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STATE LICENSE # 6 LE D CERT NUMBER
ADDRESS: � -Q < <! CITY �
PHONE " � p,e,}{ ��
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH �OOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTEN E/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: - ��� .� � ,�L ��
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING %
NUMBER OF SQUARES /
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
; WINDOWS
IN EXISTING OPENTNGS ❑Yes ONo
� OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
! TYPE OF WINDOW TO SE INSTALLED
��-iOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
❑ DRAIN TILE
C] OTHER
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ATE�!r� ZIP�
STATBl�%1�IP`�
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/�Aec.e,.�..� y �a-ys-G
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HEIGHT
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTfON MCLUDING 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 AND
MANUFACTURE STICKER ON W[NDOW.
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 $ : S See Back Page for Fee Schedule
Plan Review $ 65% of Buiiding Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ , Q $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 $ � Make checks uavable to: Citv of Fridlev Attach Sti
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 ��whic requirefs eview and approval of pla
SIGNATUREOFAPPLICANT �i..-:�.,')�.r>'-^—'� PR[NTNAME ,�L� J��i�el� DATE� � �/��
APPROVAL INSPECTOR SIGNA�—