P - 36749Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � ^ � �/ '—�
SITE ADDRESS � •S
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS r2 �
�/l U r-> G�� 6i- tS � �vC. ��--�
O OWNER �CONTRACTOR
ADDRESS: ��_���_(�/1ro�C.14-cv} S� CITY
PHONE: % fo 3` aS� - 3� a�^
NAME: ,�Ji -¢..5 �' � : r�C�-`"�t » �Gi'��
STATE LICENSE # �/, � LEAD CERT NUMBER
ADDRESS: l� l � ��� �`�r �- CITY�
�r
PHONE �� .3 � I 3 '���Z� FAX % (a 3 ^
�INGLE FAMILY/NEW CONSTRUCTtON
� TWO FAMILYMEW CONSTRUCTION
PERMIT TYPE O ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH 'J�FtOOF
❑ DECK �SIDING
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR �I2EMODEL
DESCRIBE WORK $EING DONE: �°'U'a� cF' F-� S�
SIZE OF IMPROVEMENT LENGTH WiI
ROOFING ' ❑ HOUSE ONLY
NUMBER OF SQUARES � 3�Q \ ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
� � �O
myl �
❑ Aluminum "�
❑ Other �
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
S[ZE
STORIES
❑ DRAIN TILE
❑ OTHER
Permit No.: �{,+ I'� i�j�`L7
Received By:
Date R��ro a � �
_STATEI�N ZIP�_
J
%C-- STATE �IP S�� O
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed Floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site PIan/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:
('� U ING THE 1997 U.B.0 FEE SCHEDULE)
AL JOB VALUATION $_ 'F,l �� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Swcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosiofl Control
Park Fee
Sewer Main Charge
Total Due
$ p (,B'! , Q( J
$
$
$
$
$
See Back Page for Fee Schedule
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)
$+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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
approved plan in the case of �a i orl whic ires review and approval of pla ,�/J �% r
SIGNATURE OF APPLICANT �/ � PRiNT NAME /�� ���"� DATE O—I � �l
APPROVAL INSPECTOR SIGNA URE