P - 35069Building
Inspections
763-572-3604
763-502-4977 FAX
DATE /% � `�
SITE ADDRESS _
THIS APPLICANT IS
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
PROPERTY OWNER/ NAME:
TENANT ppDRESS:
PHONE:
YOUR E-MAIL ADDRESS
�- � �
�'t�`'rT ✓l.� (i(f6 B�
� � � � r� CITY
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CONTRACTOR NAME: �'!"E� ��'—
SUBMIT A COPY OF STATE LICENSE # �JC1aSS G
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: �i�`� `� � �+i e-
INSURANCE HONE o`�I� -�a� ""�i3�1
PROPERTY TYPE SiNGLE FAMILY/NEW CONSTRUCTION
O TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE � �DITION ❑ GARAGE/SHED
❑ BASEMENT FiNISH �ROOF
❑ DECK �'SIDING
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADD[TION
�C9AINTENANCE/REPAIR ❑ REMflDEL
DESCRIBE WORK BEING DONE: ( y� S
SIZE OF IMPROVEMENT �
ROOFING / �/Z
NUMBER OF SQUARES � �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
IDING
myl
❑ Aluminum
; ❑ Other
i �WINDOWS �
', IN EXISTING OPENINGS �(Yes �No
�� OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES & p�
� TYPE OF WINDOW TO BE INSTALLED �'/�
❑ HOUSE ONLY
�"HOUSE & GARAGE
❑ ATTACHED GARAGE
S�DETACHED GARAGE
�offit
�Trim
�Fascia
LOCATION OF WINDOWS
NUMBER OF
r
FAX
SIZE
WIDTH
Permit No.:A� b� � �
Received By:
Date R�� J U � � �
STA
�S/V�"� .
T NUMBE
_CTTY � STAT� ZIP �j�
❑ DRAIN TILE
,�Pli'HER <��� �
�J
� �.
SL-fG✓
e�t�55 �.J
SQ FT
BASEMENT REMODELING SUBMIT:
1. Existing Fioor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDING 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:
ty (USING TH 997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $`� � '� OCCUPANCY TYPE
Permit Fee $ . j See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ ��,6 .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 () Non Necessary ()
Total Due $ ,(fJ�' Make checks payable to: City of Fridley Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL1D UNT[L 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 Ci ridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a pe it a o is ot to start without a permit on site; that t e work will be in accordance with the
approved plan in the case of a rkJ/" u' r�ew and approval of plan . ��j� (�Dt� o`ZC� o2� ��
SIGNATURE OF APPLICANT �- T NAME � l 1^� DATE �' !
APPROVAL INSPECTOR SIGNATURE