P - 47337Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ,� � — j � - � /
SITE ADDRESS �
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2011
YOUR E-MAIL ADDRESS /�.Y1/� I�
4 ��i�'�Sa:� S%/
❑ OWNER �CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NaME: G� i'r
ADDRESS: l ��v Q �I �C�f�'t CITY
PHONE: 7C 3"���' S�S%
NAME:
�
Permit No.: I �l�
Received By:
Date Rec'd/p ! //
h J`�"l�Ci'• Yls , /7 P �-"
STATE ��ZIP j-r���z
STATE LICENSE # /� c� -�� V SS LEAD CERT NUMBER
ADDRESS: (�y } A SO�'� d CITY r STATE��ZIP Sf/�f
PHONE �(.2 ' y�� G��'� FAX
SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF ❑ DRAIN T1LE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR �REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES ��
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
�, WINDOWS
� IN EXISTING OPENINGS ❑Yes ❑No
�� OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
' TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
� HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
HEIGHT
FT �ad�
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION (NCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. 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.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ ," See Back Page for Fee Schedule
Plan Review $ --�- 65% of Building Permit Fee
Fire Surcharge $ �., j] .001 times the total job valuation
Surcharge $ J, � i3 .0005 x Permit Valuation Minimum $5.00
License Surcharge $ , c; � pU $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= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ �, Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APP'LICAT[ON 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 wili 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 ' not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of al r ic quir r view a d approval of pl�- ,( �i, �! / /
SIGNATURE OF APPLICANT � ` PRINT NAME /�r" /' �`-�/'" �n��'l�tS DATE ( a � �� / I
APPROVAL INSPECTOR SIGNATURE / G�/.�Q �� � i /�