P - 43790Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �`V ��' � I
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
BUILDING
Permit No.:
RESIDENTIAL APPLICATION I Received By: �.
CITY OF FRIDLEY ��� T� �, ��� 1
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS C��L� n�.��-{�riar� . eo �
ReeJC i�✓'✓-
❑ OWNER �CONTRACTOR
ADDRESS:
-��a
STATE LICENSE #���
ADDRESS: ��'CJ �� � �
PHONE ��i ', 3 %s �
CERT NUMBER !�'7r
CIT'Y //((y)/f Q
FAX /fi� 5 —
PROPERTY TYPE �INGLE FAMILY SIZE
❑ TWO FAMILY/NEW CONS'IRUCTION STORIES
PERMIT TYPE ❑ ADDIT[ON ,❑ C�ARAGE/SHED ❑ WINDOWS
d BASEMENT FINISH �'ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
O SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADD[TION
AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING
S[ZE OF IMPROVEMENT
WIDTH HEIGHT
_/
ATE� WZIP S✓S�
ROOFIIYG �HOUSE ONLY �V BASEMENT REMODELING SUBMIT:
� NUMBER OF SQUARES � ❑ HOUSE & GARAGE � 1. Existing Floor Plan
A E ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GA GE 3. List of structural members to be used
PROPOSED HEIGHT: �
I I FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site PIanlSurvey showing the existing structwes
and proposed project.
O Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �Yes ❑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 COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION $�� �p OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
P(an Review $ 65% of Building Permit Fee
Fire Surchazge $ .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 fc� d�termination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Pazk Fee $ Fee Determined by Engineering
Sewer Main Chacge $ Agreement necessary O Non Necessary O
Total Due $ jd d, j Make checks payable to: City of Fridley Attach
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 d des of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application it 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 al requires review and approval of plans,�} �_C �� �� �'7 / f
31GNANRE OF APPLICANT PRINT NAME C.Ac�U DATE � /
APPROVAL INSPECTOR SIGNATURE
PLEASE NOTE: SEPARATE PERMITS ARE REO� F�R P�,UMBiN�: �t `� _-; ;� " "u �