P - 35322Building
Inspections
763-572-3604
763-502-4977 FAX
DATE '".�C,)
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER �CONTRACTOR
PHONE: G�"ti / —,�C ���'l —'
A
CONTRACTOR NAME:� ����7-'�
SUBMIT A COPY OF STATE LICENSE # %�(�� .
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: �Q� �i1//�L e
INSURANCE PHONE - � � �
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ ADDITION ❑ GAR.a<
TYPE OF WORK:
DESCRIBE WORK BEING
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ,� REMODEL
:: /YI/SC ; �i�l����4-Ti12� r �,
Permit No.:
Received By:�
D���'�� � no 1
ITY �l/.FJL-� Y S
�(/J��2� �Y� �
EXP DATE � b //
��CrrvSi`/Or2/�1%/g�.
FAX � ' �
SIZE
STORIES
❑ WtNDOWS '
❑ DRAIN TILE � �� `
❑ OTHER
��
A
STA
� s ���
�ic.n vr imrKUVr,na�,tv i LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT�
NLJMBER OF SQUARES ❑ HOUSE & GARAGE I. Existing Floor Plan
�ARAGES ❑ ATTACHED GARAGE � 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING nQ� FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vin I � ADDITIONS. & PORCHES SUBMIT
Y ❑Soffit n 1. Site Plan/Survey showing the existing structures
o A�inhminum O Trim � U and proposed project.
❑ Fascia
2. Two sets of construction plans
WINDOWS 3. £nergy Calculations
IN EXISTING OPENINGS OYes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENING$-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(US�IAjG 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 $ � nd .001 times the total job valuation
Surcharge $ ��( .0005 x Permit Valuation Minimum $5.00
License Surchazge $ $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 $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due p� $ Make checks payable to: City of Fridley Attach Stiaulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a build'irig permi d cknowledge- t the information above is complete and accurate; that the work will be in
conformance with the ordinances and co f thg.�i`ty ridle d with the Minnesota Construction Codes; that I understand this is not a
permit but only an;a.pplication or a �t �s not start without a permit on site; that the work will be in accordance with the
approved plan in th� cas w r e a d approval of /J� �,�.�,��/
SIGNATURE OF APPLIC T T NAME����� .[�/� [��..�i�! DATE � o�
APPROVAL INSPECTn iRF. �