P - 46259Building
Inspections
763-572-3604
763-502-4977 FAX
DATE (p — �( S �- �
SITE ADDRESS %f3
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
MSURANCE
TY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING {
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
BUILDING
Permit No.:
RESIDENTIAL APPLICATION Received By:
CITY OF FRIDLEY vat�'c1: � �
EFFECTNE 1-I-2011
YOUR E-MAIL ADDE2ESS g/Y� f� Z�/� � G.� A/S (���, r-y ��'Q��
/!i�(/ig'S %` c, �v �/Z �/� �� LC Y /Ll � t S u�?
❑CONTRACTOR
ADDRESS: �� / ��'N�f/i} STC7�li U2
PHONE: % rG 3�- Co O'7 - 3% J�p CL'CC
STATE LICENSE #
ADDRESS:
�INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
O ADDITION
❑ BASEMENT FINISH
❑ DECK
'�'ROOF SH�N ��S
❑ SIDING
❑ SWIMMING POOL
CITY__�/e � bL � �/ STATE��ZIP S.�y.3Z
f/o-.r► E' 7(� 3�'�/ ��� a
CERT NUMSER
[�7��1
FAX
SIZE
STORIES
O WINDOWS
❑ DRAIN TILE
❑ O'I'HER
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE/REPAIR ❑ REMODELING
.. ESNI.v��t G/��LAC�'
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
❑ DETACNED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER
WIDTH
ATE ZIP
FT
BASEMENT REMODELING SU$M[T:
l. Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing suuctures
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
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
TERIALS:
TYPE
$ �j O-�I v 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 (
� '.��— Make checks payable to: City of Fridlev
Attach
THIS [S AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 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 o k w ic/h �re�quires review and approval of pla /_ 2� f/
SIGNATURE OF APPLICANT ��,=i'-./��4� PRINT NAME �/L/ /fJ' Z�ri¢ DATE (a
APPROVAL INSPECTOR SIGNA URE