P - 43628Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �a .� CJ �
SITE ADDRESS �[�_
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMTT A COPY OF
�ou� s���� �.ic�rsE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERNII'f TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
__ EF'FECTNE 1-1-2011
OUR E-MAIL F
' �n-mdr� �-
❑ �WNER CONTRACTOR
NAME: e.
ADDRESS: %.�� f�%1I')D�
PHONE: %(m� � ��"c�j �I� p J
NAME: n �ll,
STATE LICEN3E #��
ADDRESS:
PHONE � (o� � � % tYS � /��oZ
JY'SrINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMII,Y/NEW CONSTRUCTION
❑ ADDITTON ❑ GARAG
� BASEMENT FIIVISH ❑ ROOF
O DECK i3 sIDING
❑ SWIMivL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION O ADDIT'ION
�M�T��CE�P� ❑ REMODELING
DESCRIBE WORK BEING DONE:.L�1'1 S��f �jG�-Li»l�nn�' GcJ !Y� 1✓5
SIZE OF IMPROVEMENT LENGTFi pylp�
$��G ❑ HOUSE ONLY
NiJA�ER OF SQUARES ❑ HOUSE & GARAGE
� ❑ ATTACHED GARAGE
PROPOSID SIZE: ❑ DETACHED GARA(}E
PROPOSED HEIGHT:
�
❑ Vinyl
❑ Aluminum
❑ Oth�er
wwnows
IN EXISTIN(} OPENINGS es pNo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPIIVING CHANGES & � �l�e
TXPE OF WA�Tf�OW TO BE INSTALLED q s-�
ALL FEES ARE BASED ON V,
Pernut Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazga
SAC Charge
Curb Cut Escrow
Erosion Control
Park F�
Sewer Main Charge
�
CERT NUMBER /
CITY ,1^
X —
tIES
WiNDOWS
O DRAIN TII,E
� �3TiIIt
". �... `-'""�_
---- HIIGHT
Perrnit No.: db �(��j ��
Received By: �/ � � h'
D ����' i � 2011
2 v'✓ P , LOY!'!
STATfi�ZIP_��
L -'�
�G�, LSTATE M ' ��
�-_ �_ � ��1
. /
HASEMENT RFMOD�T.TNr, . [Jghq�•
1. Existing Fioor plan
2. Proposed floor plan
3. List of stnichual members to be used
FOR NEW CONSTRUCITON INCLUDING DECKS,
OSoffit ADDITTONS. & POR .r�it?.�, cilFtt��rr�
❑ Trim 1. Site Plan/Swvey show+ing ihe existivg s�cha�
❑ Fascia �d Proposed project.
2. Two sets of conshvction plan�
LOCA ON OF WINDOWS �� �y C���a��
FOR WITTDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WIIVDOW.
.uGS �"'
NUMBER OF WIIVDOWS
.LUA ON, INCLUDING THE COST OF LABOR AND MATERIALS:
SING THE 199? U.B.0 FEE SC�IEDULE)
� ii � L�5 See $ack Page for Fce Sche�iule
$ 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 ( )
$�Sr Make ch�ks pavable to: Citv of Fridlev e rr9�
THIS IS AN AppI,ICATION FOR A PERMIT-NOT VALID UNTTL PROCESSID
I hereby apply for a building permit and T 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 s without a permit on site; that the work will be in accordance with the
approved plan in the case of. al�,�yo ch r iures review an pproval plans. �
SI(�NAT6TRE OF APPLICANT �-!/( �4��� /j p�T� M01�i/ Lr7J5/ryr, r ns� 1 b_- /n _/ I