P - 35400Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � "' Z % � r
S[TE ADDRESS (�
TH[S APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
lC, f �� 74e
❑ OWNER
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BETNG
SIZE OF IMPROVEMENT
YOUR E-MAIL ADDRESS
�. CJ✓' � �.-
�60NTRACTOR
.C, ���-� S C�vl
ADDRESS: G? �% �U Y� � 7 k Cr
PHONE:
NAME: _ t/ �n ,� P al.' H.� � fsw
STATE LICENSE # ZO to �p ��d �' ,
PHONE � Co `� � � S`� %'^ �o .
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILY/NEW CONSTRUCTION STORtES
❑ ADDITION ❑ GARAGE/SHED � W[NDOWS
❑ BASEMENT FIN1SH �,ZOOF ❑ DRAIN TILE
❑ DECK ❑ SIDiNG ❑ OTHER
❑ SWIMMING POOL
O NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAMTENANCF�/REPAIR ❑ REMODELING
Permit No.:
Received By:'� � t
Date�"�t: �1 U L � �.�1
ATE� /j/ZIP
ti �
�D CERT NUMBER
CITY /'�►'i ��' STATt��'`tiLIP�p�
Fa�c 7�3 � 7(, `�-- 9 $�/ ?
ROOFING
NUMBER OF SQUARES 2 �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
� Other
WINDOWS
M EXISTMG OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
O HOUSE ONLY
�IOUSE & GARAGE
�,'ATTACHED GARAGE
� DETACHED GARAGE
❑So�t
❑ Trim
O Fascia
LOCATION OF WINDOWS
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Pian
2. Proposed floor plan
3. List of structurai members to be used
FOR NEW CONSTRUCTION MCLUDiNG DECKS,
ADDiT10NS. & PORCHES SUBMIT:
I. Site PIan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculazions
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDI1vG THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ , See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surchaxge $ `3 .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 {)
Total Due $ �� Make checks aavable to: Citv of Fridlev Attach
THIS 1S AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is comp{ete 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 1 work whic e uires review and approval of plans.
SIGNATURE OF APPLICANT G PRINT NAME �TG� � rGZ-�K DATE �� Z g^//
APPROVAL INSPECTOR SIGt� URE