P - 35468— --- -
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �I �
SITE ADDI2ES
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTTVE 7-1-2010
YOUR E-MAIL ADDRESS D r1� �
YS"D � N �
❑ OWNER �ONTRACTOR
NAME �M 1� 1�50� � L�v I'� l yv�,,,_,
ADDRESS:�b el�'cwa E G i�� CITY_�
PHONB: i(e�- �i� T � $
NAME: �G1.4— �C�LGrG� �' •CU.�
STATE LICENSE # I I�!� Du �s Des��n & Remode��n�
11825 Point ug as S
AT3�RF.SR� .. .. _ . �_.v��
�INGLE FAMILY/NEW CONSTRLJCTION
O TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GAR.AG
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMM
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIlt ,$�tEMODEL:
DESCRIBB WORK BEING
SIZE OF IMPROVEMENT
�tOOFING
NUMBER OF SQUARES �
GARAGE�
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
iN EXISTING OPENINGS �Yes ONo
OR FOR NEW OPBMNGS-DESC1tIBE SIZB OF
OPENING CHANGES & ]
TYPE OF WINDOW TO BE INSTALLEID S(,I�Y
ALL FEES A�RE BASED�ON V.
TOTAL JOB VALL
Pertnit Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
� �1
$
$
$
$
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑So�t
❑ Trim
❑ Fascia
SIZE
PermitNo.:���%�a ��Y�
Received By:
���a ��
�x
ATE�ZIP_���.—
CITY � STATE ZIP
/_s'I - cL�_ f�/_C
❑ DRAIN TILE
❑ OTHER
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2, Proposed floor plan
3. List of structural members to be 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 Calc�lations
FOR WINDOWS – PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
��NUMBEROF WINDOWS I'T I
A ON, INCLUDING THE C S O�' LABOR
G THE 1997 U.B.0 FEE SCHEDULE)
'' OCCUPANCY
MATERIALS:
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residentiat Contractors)
$2100 per SAC Unit (Plans to NIWCC for determination)
ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Deternuned by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks oavabie to: Citv of Fridlev Attaeh
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCBSSED
I hereby apply for a building 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 will be in accordance with the
approved plan in the case of al k i r uires review and approval of pla s n�
SIGNATURE OF APPLICANT - PRINT NAME �6 �ti Vl, !`� ��� �S DATE �� �! ti
APPROVAL INSPECTOR SIGNAT
WORK