P - 36783Building
Inspections
i63-572-3604
763-502-4977 FAX
DATE �"��'
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWIVER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL AJ
� vi 4 � �% � 1�-� /�L� ��
❑ OWNER $L�NTRACTOR
NAME: �w,i I .�- Li.a�S�Y
ADDRESS:�,� y �, '
PHONE: ��� %�' 1 — � �JfS I ^
NAME: f cr L'�h,�
STATELICENSE# .�O��7J I(p.
ADDRESS: / �% �a�T S?,
PHONE (O I Z ,�� �C �
�'SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION
❑ ADDITION ❑ GARAG
❑ BASEMENT FINTSH �'ROOF
❑ DECK ❑ SIDING
❑ SWIMM
C1TY
Permit No.:
Received By:
Date 1�'e�
ATE �'�%�IP_��s �/3 Z
CERT NUMBER
CITY N�kr. IO �_STATE�iiULIP.�53n�
FAX
SIZE
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�'MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: !v
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES � �HOUSE & GARAGE
GARAGES �ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
' I ING
; ❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR T3EW OPENII3GS-DESCRIBE SIZE OF
OPENING CHANGES &
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
❑ w�DOws
❑ DRAIN TILE
❑ OTHER
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structurai members to be used
FOR NEW CONSTRUCTION fNCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. Site Plan/Survey showing the gxisting structures
and proposed project.
2. Two seu of construction plans
3. Energy Calculations
FOR WINDOWS — PROVtDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �
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
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
�rosion Control
Park Fee
Sewer Main Charge
Total Due
$ �j 'j .�S 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)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ AA. Make checks uavable 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 1 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 pe mit on site; that the work will be in accordance with the
approved plan in the case of all wo ires revie plans� �— S
SIGNATURE OF APPLICANT PRTNT NAME• T�1�°'�� �)- � S�_�DATE_� I�^
APPA(1VA1 R�TCDF(`T(1R Cil:1.IdTIfAR � �