P - 45765Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �--' t�` � �/
SITE ADDRESS � `3 SG'
TH[S APPLICANT IS
PROPERTY OWNER!
TENANT
CONTRACTOR
SLJBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2011
❑ OWNER
NAME: ./".�;
ADDRESS: ��
YOUR E-MAIL ADDRESS G � �
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I�ONTRACTOR
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PHONE: �
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Permit No.: ' -- �"�,
Received By: �� � ��:�°�w
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Date Rec' d: ^; c�` j
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STATE ZIP
STATE LICENSE # �� f � �� � / �f LEAD CERT NUMBER /L��' /!J � ��Q .� /
a��RESS: .� ���'��.''< �,,� ti crrv �, �....�.-,�' sTATE�rn,��,�y�i
PHONE /, / �— 9 �x � _ � �- 6� � FAX f � �' 5���/ .l`yS,�-' � 9
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FfNISH �'ROOF ❑ DRA[N T1LE
❑ DECK ❑ SIDING ❑ OTNER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADBITION
{�'MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES __���
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
� Aluminum
❑ Other
Q /�co
' WINDOWS
', IN EXISTING OPENINGS ❑Yes ❑No
� OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
� TYPE OF WINDOW TO BE INSTALLED
Q HOUSE ONLY
�HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffi[
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
HE[GHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION ►NCLUDING DECKS,
ADD[TIONS, & PORCHES SUBMIT:
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.
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 $ l,��' 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 pavable to: Citv of Fridlev Attach Stipulations
THIS IS 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 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
a roved lan in the case of all work h�l uire v� w an� a roval of lans�.
SI�GNATURE OF APPLICANT <�r���"'�i� �� /,n PRjT�7 N_ A�p /�.ix���cti��ATE � —02 � —0�
APPROVAL INSPECTOR SIGNA FURE 2'a�'"' % /
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