P - 45736Buiiding
Inspections
763-572-3604
763-502-4977 FAX
DATE �— � ' t I
SITE ADDRESS —f %%��
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE(
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
Na,ME: c�v
ADDRESS: II C
PHONE:�
NAME: � �.V
STATE LICENSE #
ADDRESS: S��-
Permit No.
Received By:
Date Rec'd:
YOUR FyMAIL ADDRESS .��G��C r�__l�O114 `_� ✓' C r I�OC o L!_���I
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❑ SINGLE FAMILY/NEW
❑ BASEMENT FINISH
C7 DECK
❑ NEW HOM� CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE: C�
SIZE OF [MPROVEMENT
ROOFING
NUMBER OF SQUARES ��
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aiuminum
; ❑ Other
�, WINDOWS
, IN EXISTING OPENINGS ❑Yes �No
� OR FOR NEW OPENINGS-DESCRIBE SIZE OF
� OPENING CHANGES &
CITY �{� Ci
STATE
iv�a cS�au�e �pa�u�a(p�'
LEAD CERT NUMBER
CITY '�/` STATE�IPS��v (
Fp.x �?IB- R��_"� � r
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SIZE
STORIES
❑ GARAGE/SHED ❑ WINDOWS
.�ROOF ❑ DRAIN TILE
❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WtNDOWS
HEIGHT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBM[T
l. 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.
TYPE OF WINDOW TO BE INSTALL�D 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 $ `r lJ� 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 $ �. 1fL� .0005 x Permit Valuation Minimum $5.00
License Surcharge $ `� �t� $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 Detennined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due _ $ /� 3, Make checks payable to: City of Fridlev Attach Stiaulations
THIS [S AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is comptete 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 per it 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 o r w' h re u' iew and approval of pla�?�s. r r
SIGNATURE OF APPLICANT PRINT NAM o KQL�e ��Llq`Ci DATE _ T I^� 1
APPROVAL INSPECTOR SIGNATURE '��