P - 45759Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ((J `oC CS �
S[TE 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
EFFECT[VE 1-1-2011
Permit No.:
Received By: � ' � �
��R .� 28 20�i'
UR E-MAIL ADDRESS �� I� �L�P��d( SC� 1�FS ��/'G� �(jD • Ci� l�
❑ OWNER �@NTRACTOR
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Ess: �(�,31 -� ��
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CITY
STATE �� ZIP ��
STATE LICENSE #.� (1 (� `� �� i� LEAD CERT NUMBER
ADDRESS:�(�` �. "� u�f(��{%'I'•� '�ti,ii � CITY{�%{„y.�„��/'��j STATF�i1i�.�ZIP��33�
t
PHONE ,�j,�y, -- � � � �-- I �J � � FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDTTION �ARAGE/SHED ❑ WINDOWS
❑ BASEMENT FiNISH OOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION �/�
❑ MAINTENANCE/REPAIR ❑ REMODELMG ,-. ur� ilV \
DESCRIBE WORK BEiNGDONE: �'e�V� �
SIZE OF IMPROVEIv1ENT
ROOFING
NUMBER OF SQUARES ��
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
', WINDOWS
', IN EXISTING OPENTNGS ❑Yes �No
� OR FOR NEW OPENINGS-DESCRIBE S1ZE OF
OPENING CHANGES &
� TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
�' IOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCT(ON RJCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT
l. 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 ST[CKER 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 $ � See Back Page for Fee Schedule
Plan 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 O Non Necessary O
Total Due $ �(��a,, Make checks payable to: Citv of Fridlev Attach Stiuulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 ordinanc s and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicat on fo a permit and k is not to start without a�per.�it on site; that the work will be in accordance with the
approved plan in the case of all w r which re � vi w d approvaf of plan .%,, f� �,/
SIGNATURE OF APPLICANT � - T NAME �(� IC �T ri V C��s DATE ��v'oe(/i /
APPROVAL INSPECTOR S[ RE —� � '