P - 48376B`uilding
Inspections
763-572-3604
763-502-4977 FAX
DATE��—'(Q' 1
STTE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMTI' A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
����T
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-2011
YOUR &MAIL ADDRESS CitC.,.c.�b�Lrt, �
' OWNER ❑CONTRACTOR
♦ �
NAME: 11
nnDxESS: �01 � O �Ve�'Co1�
PHONE:�� y���
--•--� /� �
Permit No.: Z G �
Received By:
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: CITY STATE ZIP
PHONE __ FAX
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
� DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR �REMODELING
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
�� / FOR NEW CONSTRUCTION INCLUDING DECKS,
� r ADDTTIONS. & PORCHES SUBMIT:
❑Soffit n 1. Site Plan/Survey showing the existing structures
❑ Trim V and proposed project.
� Fascia 2. Two sets of construction pians
�,VINDpVys 3. Energy Calculations
IN EXISTING OPENINGS OYes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE CO5T OF LABOR .ANit MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE) �
TOTAL JOB VALUATION $ B O OCCUPANCY TYPE
Permit Fee $ .�'� See Back Page for�'ee Schedule
Plan Review $ a�, l 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ 6� .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 $ � p�j ,� Make checks pa_yable to: City of Fridle_y Attact
I hereby apply for a building
conformance with the ordin c
permit but only an applic on
approved plan in the case f 11
SIGNATURE OF APPLICAN
APPROVAL INSPECTOR SIG
\
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
.rmit and I acknowledge that the information above is complete and accurate; that the work will be in
and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
r a permit d work is not to start without a permit on site; that the work will be in accordance with the
�1� ��ch�u r�p7�re iew and approval of pl�ns. , r ����
�// �/i%� .... •. /' AA/1/� P TATC /i / dV
f
I
����
�l" J
�a�mcn� 6�-�l�noryt)
,I �h! S C° S.S
��
t�1 �0 ��t�1�� ��° .
�F��dl�, �►�� s�y3�
7�3� �3q-- SNSS
�
rv�� N 3a
� G(� �
�
�
�
""' �' ,�1�. ��c+ � J I�
� �
� 1
��.s �+� P�n co N N oeS ; u�� s
���� -
, _ _