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Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �%IV�I �
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
�
BUILDING Perniit Ivo.: 2b 2-`� y�')
RESIDENTIAL APPLICATION Received By: J
CITY OF FRIDLEY Date ��� ���I ,� `� � k�
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER ONTRACTOR
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F• '�7�n?i -��^l�� ..(��ic
CONTRACTOR x�E:�t`�1iiC�Q(.� C2�r�G�
SUBMIT A COPY OF STATE LICENSE # e�(�r_7c�tpsS �'I�
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: o��` I�
INSURANCE pHONE " C� I
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE
❑ BASEMENT FII�iISH ❑ ROOF
❑ DECK O SIDING
TYPE OF WORK: I��W HOME CONSTRUCTION
DESCRiBE WORK BEING
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS �es �No
OR FOR NEW OPENINGS- ESCRIBE SIZE OF
OPENIAIG CHANGES & �
'�� e S � c�; r�cE�X�c�
CITY Y ► �
LEAD CERT NUMBER '`
ci� � �
FAX
SIZE
STORIES
INDOWS
❑ DRAIN TILE
❑ OTHER
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
O Fascia
LOCATION OF WINDOWS
WIDTH
�1 �_�_
STATE�I�(,ZIP,
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Pmposed floor plan
3. List of suuctural members to be usal
�
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.
TYPE OF WINDOW TO BE INSTALLED MBER OF WINDOWS v
ALL FEES ARE BASED ON VALUAT N, INCLUDING THE COST OF LABOR AND MATERIALS:
y ING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 1� � OCCUPANCY TYPE
Permit Fee See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surchazge $ � .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surchazge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb C�t Escrow $ ft+ 6 fi = ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ n i,( Q Make checks pa.yable to: City of Fridley 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 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 1 wo�k w' h re uire view and approval of pl,�?s�.�� C�rvv�1 f�
SIGNATURE OF APPLICANT �,����,1�� .. � PRINT NAME�{-1-Y Gi�.IQ V 1+��lJ 6� DATE� "''t,/ — I
APPROVAL INSPECTOR SIGNATU