P - 39629Building
Inspections
763-572 3604
763-502-4977 FAX
DATE � " -� L —' � /
SITE ADDRESS �%/ ,
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR E-MAIL ADDRESS /�_�"
>� / J L' iV / / • �/ �!
❑ OWNER ❑CONTRACTOR
PROPERTY OWNER/ N,�E: ,%p
' TENANT ppDRESS:�
PHONE: �
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
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NAMF.� �/J v fi�7� �
STATE LICENSE # -�o�'i3 � �.�
ADDRESS: S 3 � �%� ��! � ✓�
�PHO—NE °,� � Z' g y D -- .$ (� `.� %
'L9 SIN(iLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
Permit No • �Z —� �
Received By: (.�
Date Rec'd:_ ����
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�CITY� i'rc+����/ STA
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LE CERT NUMBER ,
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SIZE
PERMIT TYPE O ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH �ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTR[1CTION ❑ ADD[TION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �s q,4^ e9 %ic a( �� l" e vl �t� e %��
ROOFING
NUMBER OF SQUARES _� S_
GARAGES
PROPOSED SIZE:
PROPOSBD 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_ _
� WINDOWS
❑ DRAIN TILE
❑ OTHER
LENGTH WIDTH `� HEIGHT
❑ HOUSE ONLY
,�IiOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WTNDOWS
NUMBER OF
.��5/3 2
TE�%/.�GIP � � "
.s� o►,,d a�a�.:���
SQ FT
BASEMENT REMODEL[NG SUBMIT:
L Existing Floor Plan
2. Proposed floor plan
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 $ OCCUPANCY TYPE
Permit Fee $ 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 Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ /� Make checks payable to: City of Fridley Attach Stipulations
THIS IS AN APPL[CAT10N FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowiedge 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 ork which r uir s and approval of pla �
SIGNATURE OF APPLICANT ` PRl]�1T, NAME � o� ., �c� ,� I ,3-d !1 DATE " �Z % — , �
APPROVAL INSPECTOR SIG URE l.(��\
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