P - 46292Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
SITE ADDRESS _
THIS APPLICANT IS
BUILDING
RESIDENTIAL APPLICATION
b �' :
❑ OWNER
PROPERTY OWNER/ I NAME:_
TENANT ppDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
STATE LICENSE #
ADDRESS: i
CITY OF FRIDLEY
EFFECTNE 1-I-2011
YOUR E-MAIL ADDRESS
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�CONTRACTOR
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PHONE iGS�"'Z3�^ 2(o y'
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION
Permit No.: � t 1'
Rec ' y��
�
Date ec d:
STATE { �NZIP S� �_
LEAD CERT NUM$ER
CITY �L STATE�_ZIP �S�
FAX
PERMIT TYPE � �DITION ❑ GARAGE/SHED ❑ W[NDOWS
❑ BASEMENT FiN1SH �`ROOF O DRAIN TILE
❑ DECK 1�`SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION O ADDITION
�MAINTENANCE/REPAiR � REMODELING
DESCRiBE WORK BEING DONE: �£+�E h, t�Qt.t�C.�. �.�.t.Q� �}�, �•� ��►aU�s.�..�i�6� � �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING Q ❑ HOUSE ONLY
NUMBER OF SQUARES �� �HOUSE & GARAGE BASEMENT REMODELING SU$MIT:
l. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT: •
SIDING
❑ Vinyl '�irM44��. �g(�j,RG� OSoffit
,�Alumin�r►) � A � LR�� ❑ Trim
❑ Other �f _, _ _ _ �:f�1'�� ❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes DNo LOCATION OF WINDOWS
OR FOR NEW OAENTNGS-DESCRIBE SIZE OF
OPENING CHANGES &
FOR NEW CONSTRUCTtON INCLUDING DECKS,
ADDITIONS, & PORCHES SUBMIT:
i. Site PiaNSurvey 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 WINDOW.
� TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATIOI�i $ OCCUPANCY TYPE
Permit Fee $ . L 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 Chazge $ $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 $ � �'1, Make checks payable to: Cityo uf Fridley Attach Stipulations
THIS [S 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 th City Fridley and wjxh. the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatio a pe o's not rt without a per ' on site; that the work will be in accordance ith the
approved plan in the case of hich equir evi and approval of plan��'/ �I- C� �1nQ��E / %;�
SIGNATURE OF APPLICANT p PRINT NAME G� DvC.V �1 �/ v'D �Q/ �% /1