P - 39650Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �/' [ �
SITE ADDRESS
THIS APPLICANT 1S
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YO,PJR E-MA1L ADDRESS
�.�
❑ OWNER ��NTR.ACTOR
PROPERTY OWNER/ NpMg. `� �! ��
TENANT ,e.a�RESS: °5�[� ) ��e � j�- � f�� c�Tv
Permit No.:��/1 �j 7'`_
Received By: � �
Date Rec'd: - "' ! 1
A'
CONTRACTOR NAME: f, J�t ° c � �,.r >►� J �
SUBMIT A COPY OF STATE LICENSE # �>�-)� LEAD CERT NUMBER
YOUR STATE LICENSE �l'� ��
AND CERTIFICATE OF ADDRESS: ��� ('� J �%� �' l� CiTY �,� L'ft <'K STAT�ZtP�J�S�'
INSURANCE PHONE %� J ° c��C'f/ � � ") / �--_ _ F`4X —_ _ _ - .
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BE1NG
SIZE OF IMPROVEMENT
�INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
� ADDITION ❑ GARAGE/SHED O WINDOWS
❑ BASEMENT FINISH �cROOF ❑ DRAIN TILE
❑ DECK ,�SIDTNG ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION � ADDITION
❑ MAIJ;jTENANCE/REPAIR �:REMODELING
ROOFING ^� ,�/FiOUSE ONLY
NUMBER OF SQUARES c�L-� ❑ HOUSE & GARAGE
GARAGES ,����� ❑ATTACFIEDGARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
SIDING
�V�nY1 � � %� �CS� ❑Soffit
❑ Aluminum� � ❑ Trim
❑ Other Ji� Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
HEIGHT
FT
SASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of conswction plans
3. Energy Calculations
FOR WTNDOWS — PROVIDE U-VALUE AND
MANUFACTIJRE STICKER ON WiNDOW.
TYPE OF WMDOW TO BE INSTALLED NUMBER OF WII3DOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Totai Due
� ��
�
6 M /
�L.I_,t:��
See Back Page for Fee Schedule
65% of Building Permit Fee
,001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$223Q per SAC Unit (Plans to MWCC far determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Pee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks aavable to: Citv of Fridlev
Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and ac owledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances ode e City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application fo e d work is not to start without a pe it pn sit ; thalt the work wil] b�n a cordance with the
approved plan in the case of all quires ' w nd approval of pla �� / Gd�
SiGNATURE OF APPLICANT PRINT NAME ��l �' �'��^ DATE r
APPROVAL INSPECTOR SIGN URE .!n /%i--
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