P - 47287Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � / /i /
SITE ADDRESS (P
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
ERFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS � u P��
/ � V��i /Y�
❑ OWNER
Permit No.`.
Received By:
Date Rec'd: � \--��
� uJ l N C'.�i1 i:t;r�
�_ A '/ ,���u�'
ADDRESS: ''� �1—"if' N CITY �/�' (i STATE IP_5�,�r�
PHONE: �' � � � �' ��—� (v �
NAME: l.� � %u '� ? � �y N� /
STATE LICENSE # C_ ' �1-OC LEAD CERT NUMBER�/� % "I�� � ,t� % " /
ADDRESS: CITY �}'" ��� STAT� ZIPS S%/ 7
PHONE (�, ��'� =� ,���°�ia F� 6S�i -.�-9a--d�E� 5 _
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �-ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONS'I`RUCTION ❑ ADDITION
�yNTAiNTENANCE/REPAIR ❑ REMODELING �
ROOFING �r
NUMBER OF SQUARES �- %0
GARAGES
PROPOSED SI'LE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
HOUSE ONLY
HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
�Pp�o� _
SO FT
BASEMENT REMODELING SUBMIT:
1. Exisring Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
� Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
3 En Calculations
WINDOWS ' �'
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO B� INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
�,,,p (j � OCCUPANCY TYPE
$ � See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ � .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ ,o�,, $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
� .% Make checks pa.yable to: City of Fridle.y Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work wil�e in
conformance with the ordinances and codes of the City ridley and with the Minnesota Construction Codes; that I understand this is not a
pernut but only an applicatio for a permit an work is ot to start without a permit on site; that the work will be in accordance with the
approved plan in the cas� ali o hich ,Gqui s ie and approval of plans. / /
APPROVAL INSPECTOR � �� P TNAME G�U � DATE_�%�°`/ �/�
�NA"�` _ � _ � _ --