P - 46271Building
Inspections
763-572-3604
763-502-4977 FAX
DATE lp o�� II
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIF'ICATE OF
INSURl�NCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
BUILDING
RESIDENTIAL APPLICATION
CIT� OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER
ADDRESS: �Z(� `1 L � I�'_( X Ir V 1 E'C.�.!
PHONE: �L1 I p� — 3�� ^� 3 5 ��
NAME: � u,C� b5 l S.: k C.�'1
STATE LICENSE # � Q� � � � �Z �
annxESS:_�} 1 cj � N W�v
PHONE �U`] I � �G�- � " � � � FS
�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
NEW HOME CONSTRUCTION
ROOFING
NUMBER OF SQU�A[R�E��.
GARAGES ROQ�
PROPOSED SIZE:�Ci S
PROPOSED HEIGHT: �
5IDING Q �
❑ Vinyl 3
❑ Aluminum
❑ Otlrer
CERT
FAX (a� 1 "
SIZE
STORIES
❑ GARAGE/SHED ❑ WINDOWS
�$QOF ❑ DRAIN TILE
❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDTl'ION
❑ REMODELING
LENGTH WIDTH
Permit No.: Cil�l lriJ
Received By:
Date Rec' d: . ,,� . „ ,� ,
STA"I'E��I ZIP,�s�a �
❑ HOUSE ONLY gASEMENT REMODELING SUBMTI':
�HOUSE & GARAGE� � � � S O
1. Existing Floor Plan
❑ ATTACHED GARAGE �� O 2. Proposed floor plan
❑ DETACHED GARAGE � 3. List of stn�ctural membeis to be used
� l G ��O FOR NEW CONSTRUCT'ION INCLUDING DECKS,
��fft I ADDITIONS. & PORCHES SUBMIT:
❑ T� 1. Site PIan/Survey showing the existing structures
❑ Fascia and ptoposed project.
2. Two sets of conshuction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No I.,OCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE t1ND
OR FOR NEW QPENINGS-DESCRIBE SIZE OF MAN[7FACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED Ni.JMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATER�iLS:
SING THE 1997 U.B,C FEE SCHEDULE)
COTAL 30B VALUATION � ��O ,� O O OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tota! Due
$ f►�. Z$ See Back Page for Fee Schedule
$ 65% of Building Pernut Fee
$ .001 times the total j� valuation
$ .0005 x Pernut Valuation Minunum $5.00
$ $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determinarion)
$ ft+6ft= ftx$25=$
$ $450 ConservaUion Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessaiy { )
$ �. Mske checks navable to: Citv of Fridlev Attac
THIS IS AN APPLICATION FOR A PERMTT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acl�owledge that ti� infor�tion abave is complete anci accurate; that the work will be in
co�ormance with the ordinances and codes of the City of Fridley and with the Minnesata Canstruction Codes; that I understand this is not a
permit but only an application far 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 all wo k which requires review and approval of plans.
SIGNATURE OF APPLICANT P IN'� NAME 'L4,..,iS"C� til �1 'iF��TE C� Ii �� � 1
APPROVAL INSPECTOR SIGN `� �