P - 37251.
n
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE / - � � � 1 I
SITE ADDRESS �Q
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:
f ,�L� , � � .���� f_ `�
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE ]-1-2011
❑ OWNER
NAME:
YOUR E-MAIL
�CONTRACTOR
PHONE: %�� � � �
NAME L�/�rI
STATE LICENSE #__ _
LEAD CERT
AflDRESS: CITY [�,
PHONE 4�.,_: .�,. .[,_ � FAX
---.._ . _. . �_._. ..�_ ____-�, .._..__.�.�..___�_....___,..__�
� SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
� ADDITION ❑ GARAGE/SHED WINDOWS
❑ BASEMENT FINISH �ROOP ❑ DRAIN TILE
❑ DF.CK ❑ SIDWG ❑ OTHER
❑ SWI'NIMING POOL
❑ NEW HOMECONSi'RUCTiON L] ADD[TION
�MAINTENANCE/REPAIR � ❑ REMODELING
Permit No.:
Received By:
Date R��� �`"��
l .
STATE�ZIP�
a-
�1 STATE U��ZIP �
DESCRIBE WORK BEING DONE: r ` � ) �'�[� $ 5 ~ �W �Y�`� ��u
SI7.E OF IMPROVEMENT LENGTH WiDTH HEIGHT SQ F1' �'
ROOFING '� �HOUSE ONLY � /� � �
NUMf3�R OF SQUARES .__� � ❑ HOUSE & GARAGE ��`' '- � BASEMENT REMODELING SUBMIT:
� l. Existing Floor Plan
GARAGES �{-� � ATTACIIF,D GARAGE 2 Proposed floor plan
YROPOSED SI7E: � ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NFW CONSTRUCTI02�3 INCLUDING DECKS,
� SIDING ADDIT(ONS. & PORCHES SUBMIT:
❑ Vinyl ❑Soffit l. Site Plan(Survey showing the existing structures
I❑ Aluminum ❑ Trim O and proposed project.
❑ Other ❑ Fascia / Q'� 2, Two sets of construction plans
WINDOWS ,�, �'��� v 3. EnergyCalculations
OR FO]R NEW OP NINGS-DESCR❑IBE SIZE OF L�.Sp__ �'jiQ �W�NDOW d� �� A _ POR WINDOWS - PROVIDE U-VALUE AND
(l�afL MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & � C qSQMP� �
TYPE OF WINDOW TO BE INSTALLED D{k NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND A�IATERIALS:
(USING THF 1997 U.B.0 FEE SCHEDULE)
TOT�L 3�� V�L'UA; 3�::' $ � oo t��� ` ,�,[��r ip.4Nl~y TYP�
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ ' G .001 times the total job valuation
Surcharge �$ �2� � -- .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 Revie�v
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ '�(�_ " Make checks a able to: Cit of Fridle Attach Sti ulations
7'FIIS IS AN APPLICATION POR A PERMIT-NO'I' VAL[D UN1'IL 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 th 'ty of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicati r a permit nd or i not start without a permit on ite; hat the work will be in accordance with the
approved plan in the case o all w rk whi r ui d approval of pla . � ,� /�
SIGNATURE OF APPLICAN"C PRINT NAME DATE � [
APPROVAL INSPECTOR SIGNA E
PLEASE
u