P - 48075Building
Inspections
763-572-3604
763-502-4977 FAX
DATE I �- �' � 1
SITE ADDRESS S 3 ,
THIS APPLICANT 1S:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
1NSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
O Aluminum
❑ Other
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 11-2011
Permit No.: Z �
Received B •
Da'tL R�'d��
E-MAILADDRESS �hc�wr� � K— � R�rv.c,Cla I�`r�C ry..�'
❑ OWNER �CONTRACTOR
PHONE:
STATE LICENSE # �� C � � O
❑ SINGLE FAMILYMEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
(�BASEMENT �i�+`" ❑ ROOF v
❑ DEGK ❑ SIDING
❑ SWIMM
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
��
� CITY � � eL�
( LC
LEAD CERT NU
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
� HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
ATFI,�I�,�ZIP S S� �-[ �
❑ DRAIN TILE
O OTHER
�
�:L��t3:M�i
ATE/'IIVLIP�_
FT
BASEMENT REMODELING St�3MIT•
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural membeis to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑So�t SIDING/SOFFIT/FASCIA ADDITIONS & PORCHES SUBMIT•
❑ Trim REMOVED? ❑ YES O NO �• Site Plan/Survey showing �he existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
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 BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INC�,UDING THE COST OF LABOR AND MATERIALS:
, (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Suroharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
TYPE
� /:S . j�S See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �o� .001 times the total job valuation
$ �S .0005 x Permit Valuation Minimum $5.00
$ ��— $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 payable to: Citv of Fridlev Attach Stioul.
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 will be in
conformance with the ordinances and c des of the Ci of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a pe 't and w is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of wor ich eq ' review and approval of ans. O
SIGNATURE OF APPLICAN PRINT NAM�I�c,�.,� 10�� �� DATE I�' J`� `% Z
APPROVAL INSPECTOR SIG ANRE
�
.
.., • .r
�. . , _
� � 1��
-
��� � N ������ � T�
� s1� � �►r �i"'� t ,�,� �� .
�r� —_._,_„�
L�c.�..�.. � .--- i./�` � t iJ 'i'S'' / ,'' ' --
_�___.--------____--- -_--_.__.._� --.._____--- -- -- -----
�����_ ,_ _ � ' � I � ��2 � --� � �
�to ���
s
1�1�� S ---1 �-I
�: ►��
� . � ;? rr �
�..
��t �� � .
0
���, � .
� �=
fi
.
N�t t i.I .
� �-1 r -`� �'(� `� C `f �
" �
��, �
_ _ €.0 wt� ----
--�� -.� � _ -
_s �����c�
.
�.. '� S _ -- z
.
►�. t�v ._._ �'_.�u_�,
_ ��� 1 �P
z
�