P - 44170� �a- �-s . �
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 1 b � � �'
SITE ADDRESS �-P �� �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SU$MIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLE`�
EFFECTIVE 1-1-20ll
YOUR
D-.
❑ OWNER
NAME: � � f�.. � t
ADD�SS: � a � , N� CITY �,-�< �c r
PHONE: � � c� ! S� I ' �"'1 '�- �'
STATE LICENSE # G
ADDRESS: �a� J
„r,,,�,.. /:. ia��"�
�SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION �TARAG
❑ BASEMENT FINISH I� ROOF
❑ DECK Y] SIDING
❑ SWIMM
W HOME CONSTRUCTION
MAINTENANCE/REPAIR
0
LEAD CERT NUMBER
• A�' � � � CITY�
FAX � � �-- a
SIZE
STORIES
ED ❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
❑ ADDITION
❑ REMODELING
PermitNo.:2.� ��d����
Received By:
Dat��;�}l: �
'2P�W� ? n c . Ct�r�-,
STATE IiZ�IP � 3
�7- �1��`i-1
STpA�TE�/NV ZIP
—' dc���(�
DESCRIBE WORK BEING DONE: � r� OT' ���SQ U f�tr l e 5
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NLJMBER OF SQUARES �_ ❑ HOUSE & GARAGE 1. Existing Floor Plan
�ARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: � DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
��G FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vin 1 ADDTTIONS, & PORCHES SUBMIT:
Y ❑Soffit ], Site Plan/Surve showitt the existin structures
❑ Aluminum ❑ Trim Y g g
❑ Other ❑ Fascia and proposed pmject.
2. Two sets of conshucrion plans
)'VINDOWS 3. EnergyCalculations
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, INCLUDING THE COST OF LABOR AND MATERIALS:
(USIN THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $� c O O� OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $—��-�— .001 times the total job valuation
Surcharge $ .0005 x Pernut Valuation Minimum $5.00
License Surcharge $ 56�j $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft + 6 ft= ft x$25= $
Brosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Deternuned by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ •�-' Make checks payable to: City of Fridlev Attach Stipulations
T IS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit nd I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and co es of th ity of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a pe it an ork is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case o k whic uires rev' and a roval of pl e,� t/
SIGNATURE OF APPLICANT T NAME_ ���'G� R-VC� ll DATE � �II��� � I
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