P - 35959Building
Inspections
763-572-3b04
763-502-4977 FAX
DATE��
SITE ADDRESS /
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2011
YOUR E-MAILADDRESS .� M/ S S/ �
9 C �'
❑ OWNER �ONTR.ACTOR
Permit No.:
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ADDRESS: 7� 7j /��i G�iC��/'� %��r�TCITY ��/ C��� �/ STATE/v%/�ZIP `
PHONE:
NAME: �� � /YJ , n CY�/t�0",�' �NC — O �✓
STATE LICENSE # � LEAD CERT NUMBER
ADDRESS: � C U� CITY �//C �r�(/�/' STATFJyNZIP Ss3.��
PHONE �"� Z Zl '� 3�Z b FAX !�o �" �S �" C O b%
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �"ROOF � DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE �F WORK: ❑ NEW HOME CONSTRUCTION � ADDITION
❑ MATNTENANCE/REPAIR ECREMODELING
DESCRIBE WORK BEING DONE: �� �C� A�
SIZE OF [MPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES/�_ �NOUSE & GARAGE I. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
� 3I_ DING
i ❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WiNDOWS
NUMBER OF
FOR NEW CONSTRUCTION INCLUDING 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 STICKER ON WMDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 �EE 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 $ .00OS 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 $ 0� Make checks pavable to: Citv of Fridlev Attach Stiaulations
THIS IS AN APPLICATION ROR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the infonnation 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 al rk which requires review and approval of plans. �+ c� /
SIGNATURE OF APPLtCANT �`�' � PRINT NAME�','�'�� f� NI� 5���/ DATE l� 'Tl �" (�
A Dl�Dllt) A I T.T(��]CI�TAi] (�il�Ll �