P - 46714Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY OW1vER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
; DESCRIBE WORK BEING
C
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.:
Received By: `
Date Rec'd: — `� �
YOUR E-MAIL ADDFtESS t�'�0 � G I PJit r C�B r�G2 (�eS�w'I� O�J �
�Cn'7�-y � ]F'rVe /l/E
�ONTRACTOR
./,�._�0.._ ^_ .
ADDRESS: �+ S'Q�.� ag a �o�. CITY �"•\c�
PHONE: (�S� , �%�, r����
ATE�Z[P�S'l�'32
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: y�� C�.raSSo (-t����S r, CITY �S�e.v� �t'� STATF�'►1I1/ZIP ,�S`/!
PHONE 6 I Z� Z$� �/ .�7 / 7 7 FAX L� ( 2•�2S�i � 7 f 7 Z
❑ SiNGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILYMEW CONSTRUCTION STORIES L
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH �OOF
❑ DECK IDING
❑ SWIMMfNG POOL
❑ NEW HOME CONSTRUCTiON ❑ ADDITION
❑ MAINTENANCE/REPAIR �'REMODEL.
.,. R�C— �eJ�!- �'� � ew.e�n � G'1-�
R OFING ��� —
, NUMBER OF SQUARES
', GARAGES
i PROPOSED SIZE:
' PROPOSED HEIGHT:
SI�
myl v `� S� �`02 7SD ;xX
Aluminum /
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
�.L-IOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
❑ DRAIN T1LE
� OTHER
�S. (�ts� d�. +�e.A r�C I e U
HEIGHT SO FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to bc used
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. 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 WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ . 2� OCCUPANCY TYPE
Permit Fee $ '7 � 2 See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ ,�.001 times the total job valuation
Surcharge $ q,jC�0005 x Permit Valuation Minimum $5.00
License Surcharge $ ,,Q�,$5.00 (State Licensed Residential Contractors)
SAC Charge $ � $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft = 8 x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $��j��'� Make checks pavable to: Citv of Fridtev Attach
lations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a bui�ding 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 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 wiil be in accordance with the
approved plan in the case of al ork whic e ui e r view a app'�val of pl s. �
SIGNATURE OF APPLICANT � I NAME _�Gqcer /lI%S%i JS �. DATE 1 t I 1 S J F I
� K
APPROVAL INSPECTOR S[GNA E _�e�&� 1 �y�„
/1 `Fl.
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