P - 46517Building
Inspections
763-572-3604
763-502-4977 FAX
DATE I
SITE ADDRESS _� �
i THIS APPLICANT IS:
� PROPERTY OW1vER/
TENANT
i
CONTRACTOR
SUBMIT A COPY OF
� YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
; DESCRIBE WORK BEING DC
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
�i i � `e�i% J' Y �— .
❑ OWNER 23�ONTRACTOR
NAME: !U l� . �
ADDRESS: i��
��( I ✓� �.0
PHONE: ��) —p VO �' �'�S
NAME:
STATE LICENSE #�39 ��
ADDRESS: � 1 � �O �D ��SG�I'1 � °
PHONE n.S I� O K��. �-g l
Permit No:
Received By:
Date Rec'd:�_4-�
CERT NUMBER
CiTY I STATE IP_�
.IRSINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION � GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ,�ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION � ADDITION
� MAINTENANCE/REPAIR O REMODELING
ROOFING '�I-iOUSE ONLY
! NUMBER OF SQUARES ,�� ❑ HOUSE & GARAGE
, GARAGES ❑ ATTACHED GARAGE
i PROPOSED SIZE: ❑ DETACHED GARAGE
' PROPOSED HEIGHT:
SIDING
❑ VinY� �Soffit
❑ Aluminum ❑ Trim
❑ Other ❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE S[ZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINL
f�
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 SUBMIT
1. Site Plan/Survey showing the existing structures
and proposed project
2. Two sets of construction pians
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 MATERI.
SIN THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �� �p� ___ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �j`T.2S
$
$
$ ,
$ �a
$
$
$
$
$ — -
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job vatuation
.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 UNTIL 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 code of the Ci Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit a d wor i not to start without a permit on site; that the work will be in ccordance with the
approved plan in the case of al rk hich re ' e r iew and a roval of la.�ns- ,n J//
SIGNATURE OF APPLICANT PR NT NAME p,.1 a�,/� �J/'L��_af y DATE I� / 7
APPROVAL INSPECTOR SIGNA E _ �`"�s, ,
��� �