P - 37253Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 7j'' � - �'
SITE ADDRESS _�.�_
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY 4F FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER �CONTRACTOR
NAME: � (llln �f1�S\I
ADDRESS: I J-� GYd Z`J LD K�iVI't� vi.9 �<pl CITY
PHONE: (olo� " )OZ r 7a� �
Permit No.: V � "�
Received By: �
�� ��� � � ��
106� , �iv�t
STATE �� ZIP �` � <
i���r� ./ li'lAl �i�il/I lV!_] L'l .�/ aJ � y�—� .
STATE LICENSE #� ���l 7S, l LEAD CERT NUMBER /" � T° W7 �I �O ^ I
ADDRESS:I-O?Oi 7J ��JvF . JVl7E E CITY !� �i� STATt�-v✓ ZIP SS�J'(�
PHONE �� "3 �" b� Q O FAx `7�3 -3I S'- 8'�r Y��
�SINGLE FAMILY c8id�ii�IiUlv SIZE
❑ TWO FAMIi,Y/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH `�ROOF ❑ DRAIN TILE �5.�/'IM C J�2,�/�£�
❑ DECK ❑ SIDING ❑ OTHER � � � � �X
C7 SWIMMIiVG POOL
� NEW HOME CONSTRUCTION 0 ADDITION
�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: C' Qj-^} - Q��f� i,
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES � �'iIOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCT[ON INCLUDING DECKS,
D Vinyl OSoffit ADDITIONS, & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF W�NDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTUR� STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUAT[ON, INCLUDING THE COST OF LABOR AND MATERIALS:
USI1�G THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $% O� �' OCCUPANCY TYPE
Permit Fee $ ` v' _ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ ��(�(p .001 times the total job valuation � jf
Surcharge _$ �;,3 .0005 x Permit Valuation Minimum $5.00 �/.,,
License Surcharge $ S(�� $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 _ _ $ (�0, Make checks payable to: Citv of Fridlev Attach Stiuulations
THIS [S 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 a d d s o the City of Fridley and with the Minnesota Construction Codes; that i understand this is not a
permit but oniy an application f ► d w is not to start without a p it on site; that the work wiit be in accordance with the
approved plan in the case of all w � s eview and approval of pla "—' �/�^//
SIGNATURE OF APPLICANT PRINT NAME DATE /
APPROVAL INSPECTOR SIGNA URE
PLEASE NOTE: SEPARAT'E PE T.ARE RF. U Fl� FnR FT.iTMRiN(', F.T.F(`T12Tf`,4i, At�F[111hFCXltii�3Tf'AT. �tttt'�tti� '.