P - 39911Building
Inspections
763-572-3604
763-502-4977 FAX
DA"I E__�__(=(_ � _ I
SITF. ADDRESS ._�_�_�_�
TH15 APPLICAN'1' IS:
PROPERTY OWNER/
TENANT
BUILDING
RESIllENTIAL APPLICATION
CITY OF FRIDLEY
I;FFECI�IVE I-I-2011
❑ O�VN ER
NAME:�Qi� �L�:
ADDRGSS: �
PHONC:�l03 70�'
R G MAIL ADDRIiSS __
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AC"I'OR
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v.vi t,Pt M/! I�i'lc ➢ �
CONTRACTOR NnMr: r
SUBMIT A COPY OF �
YOUR STATE LICENSG STA"I'E LIC6NSE # LEAU CF.RT NUMBEP
ANDCGRTIt'ICATEO}� ADDRf:SS:_�_ � �--- - � -- --CI]Y�i
INSUR�NCE pt-�pNF - rAx
F`ROPG32TY TYPE SI"JGLI� i� ^."✓1SLi';Nl�l�' CO*±S"TRUC"rlQN CIZF
❑ TWO PnMILY/NGW CONS'fRUC"I�ION STORIGS
PERMIT TYNE � �DDt7'ION ❑ GARAGG/SHGD ❑ WINDOWS
❑ E3ASGMEN'I� FINISH �QROOP ❑ DRAIN TIL[:
❑ DECK O SIDING ❑ O"I'HER
❑ SWIMMING POOI.
TYNE OF WORK: ❑ Nrw EioMe coNS�raucnoN ❑ A�nrr�oN
� �MAfN'fGNANCE/RCPAjR ❑ RGMODELfNG
� �a, ��
v
Permit N�.: �'�
Receive� By� ��
Dat����d: ; �w,., �_ � �
s�rAr�; I�q►v.��
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DLSCRI[3G WORK I3F;ING DONG.___ '�lLJ _,_ —
SIZE OF IMPROVEMGNT LENG'I II WID"1'H_ l�{EIGI1'I' SQ f T
ROOFI\G ❑ 1IOUSE ONLY [3ASFMF�NT RGMODGLING SU[3MIT:
NUME3ER OF SQUAR6S _ �EIOt1SE & GARAGE �_ Existing Floor Vlan �
GARAGGS j�AT'TACIIF.D GARAGE 2 Proposed floor plan
PROPOSGD SIIE: � ❑ DETnC1iEU CiARAGF. 3. List of structural members to be used
PROPOSED HGIGH'Ii—
� FOR NEW CONSTRUC'I'ION INCLUDING DECKS,
SIDING AnDI"f10NS & PORCIII:S SUF3MIT:
❑ Vinyl ❑Soffit � Site Plan/Su��ey showing the existing structures
❑ Al�uninwn ❑ '�rim and proposed project.
�❑ Other � f'��c�a 2. �� 7'wo sets ofconstruction plans
WINDOWS 3. Energy Calculations
�� IN EXIS'1'ING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS —PROVIDE U-VALUE AND
OR I OR NGW OPENINGS-DGSCKIl36 SIlB Of' ___ __ ___ MANUFACCURE STICKGR ON WWDOW.
OPENING CHANGES &
TYPE OP WINDOW TO L3E INSTALLED NUM[3GR O[� WINDOWS
ALL FEES ARE [3ASED ON VALUATION, INCLUDING TIIE COS"T OF LAI30R AND MATERIALS:
USII�('pTI��IF, 1997 U.B.0 FEE SCHEDULE)
'f'OT:� L JOB VA[,UATI�JN ���� • OCCUPANCY TYPE
Permit Fee $ ��r 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 Minimu+n $5.00
� License Surcharge $ L� _$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 L'ngineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Totai Due $ Malce checics a able to: Citv of Fridle Attach Sti ulations
T{IIS IS AN APPLICA"I�ION I�OR A PERMI'1'-NOT VALID UN"CIL PROCESSED
I hereby appiy 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 the City of Fridley and with the Minnesota Construction Codes; that ] understand this is not a
permit but only an applic on or a p ' a d rjc is n t to start without a p rmit on site; th t the work wilt be in accordance with the
approved plan in the case f all ork whic re r- e e nd approval of plan ��� -��'--�-�—_�-
SIGNATURE OF APPLICAN"1 PRIN"1' NAMG: DA"I�C
APPROVAL INSPECTOR SIG
PLEASE NOTE: SE RATE PE IT REQUIKEU FOR pLUMI3ING, ELECTRICAL AND MECHANICAL WORK