P - 37479Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � (X �J" " 11
SITE ADDRESS j �
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
Permit No.: ���� "� �4�
Received By: z,�j,���,��i�
CITY OF FRIDLEY Dat���'a�.1� 9i ,�����
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS J�,J}, (� e �� D./t, (� (f l f1r tJ� Ci1 /��`i'(j�('�'rCi f) LLC�
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❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME:
TENANT
ADDRESS:
PHONE: i
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTffICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT_
NAME: (�y i� a
STATE LICENSE #
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.: �. CITY ��'� t�+E- i.� STATE I��IP
CERT NLIMBER
CITY bt?�aq-j�C� STATE�ZIP
PHONE � SO� ' t� e�U'" 3�� Cp FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED O WINDOWS
❑ BASEMENT FINISH �ZOOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMtNG POOL
❑ NEW HOME CONSTRUCT[ON ❑ ADDITION
'�t,MAINTENANCE/REPAIR ❑ REMODELING
ROOFING /�`
NUMBER OF SQUARES � "�
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
� Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE QF W[NDOW TO BE INSTALLED
❑ HOUSE ONLY
�HOUSE & GARAGE
l�ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
HE[GHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of struc!ural members to be used
FOR NEW CONSTRUCTION [NCLUDING 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.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $� �y''C3 -�C� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
i Park Fee
I Sewer Main Charge
! Total Due
$ ��`(, 1-5 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ � .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25°$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ h/) , In Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERM►T-NOT VALID UNTIL PROCESSED
I hereby appiy 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 code 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 perm t nd 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 which equires r v' w and approval of p}�n�. ,�� n����ATE �" a 3- �
SIGNATURE OF APPLICANT PRINT NAME �� ►!/ (
APPROVAL INSPECTOR SIGNATURE