P - 48303Building
Inspections
763-572-3604
763-502-4977 FAX
DATE V L _ `U
si� anDxESS ( �
1'HIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMTT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING DC
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
YOUR E-MAIL ADDRESS � � � N�
NF
O OWNER
Permit No.: L
Received By:
Date Rec'd:
�
�w�.S. Cri�
NAME:_ �Olif � Ly0 ►J N Q� 1N1 ar 1•�
ADDRESS: �.���,,� Q� ,�-C ��a/-P CITY STATE ZIP
STATE
Wl!
.�
r
ADDRESS:_ p'I �S d � �
PHONE �Ib`� ��ZQ�.��<<
SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
O ADDITION � GARA(
❑ BASEMENT FII�iISH ❑ ROOF
❑ DECK 19'SIDINC
O NEW HOME CONSTRUCTION
❑ MAINTENANCElREPAIR
SIDING
O Vicryl
� ����
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
� X} 2lri��rS � ,�. N�
LEAD CERT NUMBERI3 AT"
t L�a y 1J crrx O SS
FAX `l (o� . �'�
SIZE
STORIFS
i/SHED ❑ WINDOWS '
� DRAIN TILE
❑ OTHER
NG POOL
O ADDITION
❑ REMODELING
� N 2�S �
WIDTH HEIGHT
0 ATTACHED GARAGE
❑ DETACHED GARAGE
�offit SIDING/SOFFIT/FASC7A
I$'Trim REMOVED? �1'ES � NO
g� ia E �
LOCATION OF WINDOWS
� 5S'�b
�
BASENIDVT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural �mmbers to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS_ & PORCHES SUBMIT:
1. Site PlanlSurvey sFwwing tl�e existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WiNDOW.
-
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
,i��� G THE 1997 U.B.0 FEE SCHEDULE)
JOB VALUATION $ t%,'7U� n('('iJPANC'Y 'rvpr.
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
S `G �� ��'� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum or .50
$ S $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fce Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$—� �-(7,— 1 Q�— Make c6ecks payable to: City of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes e City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only ar► applicaf or pe k is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case o 1 orl wh' � re iew and approval of pl�{s. 1 ^�
SIGNATURE OF APPLICANT PRINT NAME_ #{�2.�C �$,���A S"�� DATE_ O L,O�i .� o�
ADDDAVAi TUCDII/`TAD Q7!_I.IATfTDC i I - C