P - 43789Building
Inspections
763-572-3604
763-502-4977 FAX
DATE I�`I �~j
SITE ADDRESS �
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
YOUR E-MAIL ADDi2ESS
d�1 S'T �UF
PROPERTY OW NER/ NqME:_ �6 ('j r� rt- � d V t
TENANT qDDRESS:� dS �"�CIC� s��� CITY.
PHONE: LG �' �� "ZrZO%
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
N,v�E:_ �S r`al C� E
STATE LICENSE # �
ADDRESS• SjO [v
C��
�"1 L+f� 1!
PHONE � f �..^ �% � � '- � � � �T
�' SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION
0 BASEMENT FINISH R�JtOOF
❑ DECK ❑ SIDING
❑ SWIMM
L
Permit No.:
Received By: '� � y �
Date Re�;� � � � �. �
� mr� fis-k � �
� Q y STATEP
Liat'Yl � �r1 �OV'F/'�
CERT NUMBER
CITY �. �' 0 L�/4C� STA
FAX h%� l ^ •� ?f`'1.'•
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
TYPE OF WORK: 0 NEW HOME CONSTRUCTION ❑ ADDITION
�$ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: /Z 0 0 C`'Ih� � N}4 d- ��-- Ie�Ci f
SIZE OF [MPROVEMENT LENGTH WIDTH
ROOFING �HOUSE ONLY
NUMBER OF SQUARES � �HOUSE & GARAGE
GARAGES � ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
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_
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
f-� �- r oo'�'
HEIGHT
FT
�.SD!
BASEMENT REMODELINGSUBMIT:
1. Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDiNG 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 $ �-SO � OCCUPANCY TYPE
Permit Fee $ -� See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ 33� .001 times the totat job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $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 Chazge $ Agreement necessary () Non Necessary ()
Total Due $ . J Make checks pavable to: Citv 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 wil] 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 a wor whi re ui e review and approval of pla . �f �� e c k /� /
SIGNATURE OF APPLICANT � PRINT NAME ��"1 P Y DATE,� O~�7'^ `I
APPROVAL INSPECTOR SIGNATURE � r—