P - 35765Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �,S °
SITE ADDRESS �
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YO/U�R^ E-MAIL ADDRESS
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❑ OWNER �LONTRACTOR
PROPERTY OWNER/ NAME:_/�pqGt� � C2IP
TENANT —�
ADDRESS: �%�%S(� L�tI;
PHONE: �%.7 "" 7�([e �'
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMTT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
STATE LICENSE #
ADDRESS: / I Z
PH NE ��3-' %� � 9Z
SINGLE FAMILY/NEW CONSTRUCTION
� TWO FAMILY/NEW CONSTRUCTION
� ADDITION ❑ GARA(
Permit No.:
Received By:_�
Dat��i: ' � � �
I �es��ra f,'v�► �Ha.��
OCtGi N� CITY� � I �
.�»G.
LEAD CERT NUMBER�
,
� C1TY I,�w%�/a �
❑ BASEMENT FINISH � ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENAN�E/REPAIR ❑ REMODELING
:: �P- r�e . P-SI" 2 /2 � 2�e�a /av� � v
� ROOFING n
NUMBER OF SQUARES Z l�'
GARAGES �O
PROPOSED SIZE:
I PROPOSED HEIGHT:
': SIDING �
; ❑ Vinyl
❑ Aluminu r,,,
�Other �.�5/hGY�t/�G �
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
O �-IOUSE ONLY
�;HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
�rmt �e�� �'Ie✓a/��f�i
Fascia
LOCATION OF WINDOWS
F
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
STATE��V Z[P .SS ,3Z
ATF,�%�IZIP ssyzJ
ss�sj
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
�1-td
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing structures
and proposed proiect.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF WMDOW TO BE INSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ Z � OCCUPANCY TYPE
Permit Fee $ ,Z�� See Back Page for Fee Schedule
Plan Review $ � 65% of Building Permit Fee
Fire Surcharge $ .001 times the total 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 Contro) $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ Make checks a able to: Cit of Fridle Attach
THIS IS 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 all rk which u' es review and approval of pCans. /'+ �r�
SIGNATURE OF APPLICANT �. PRiNT NAME � ��� (� ��_ DATE 3 /
APPROVAL INSPECTOR SIGNA UR '