P - 35827Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�
S1TE ADDRESS �
THIS APPL[CANT IS:
PROPERTY OWNERJ
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
_ YOUR E-MAIL ADDRESS ��/ � �-tii
❑ OWNER G�,ONTRACTOR
CITY
Permit No.:
Received By: � �
����,:o�� � � �.�1�
STA'
CONTRACTOR NAME: �GIQ RtlOE+'�t�1 c �R�c�+oc�t.\ic�a
SUBMIT A COPY OF STATE LICENSE # IO� LEAD CERT NUMBER NpT- a5o3y�
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: 4�� �Ct4'iiC'�' i3\� CITY'$�r.�0uis �►,at, STATE
INSURANCE pHONE g'S�-�i15-7?�t FAXC{67 � �i.Za,-
PROPERTY TYPE �B'SINGLE FAMILYMEW C�ONSTRUCTION SIZE
� TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �'1�OOF
❑ DECK ❑ SIDING
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: !X
S1ZE OF IMPROVEMENT LENGTH WCDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES _�O O HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
S[DING
❑ Vinyl
❑ Aluminum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ DRAIN TILE
❑ OTHER
�'�����
Ua�
HEIGHT SO FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHES"SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXiSTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE 3TICKER ON WINDOW.
OPEN]NG CHANGES &
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 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$24 =$
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge 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 ] work which re uir� re�ew and approval of p ans. `�
SIGNATURE OF APPLICANT ������� �1/�1 ' PItINT NAME�� I�,�.1 i�.�C DATE � I�1' �(
PLEASE NOTE: SEPARATE PERMITS ARE REOUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK