P - 48534Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � • � d� ' ��
SITE ADDRESS ( 3 5 �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
BUILDING ��(�►`'
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-]-2011
YO R E-MAIL
� ��
❑ O ER �60NTRACTOR
rrAME: �t �Yr � �
ADDRESS: � �� p �
PHONE: � �3 — S 7c� —
CONTRACTOR NAME: L:l,�.d�.b�yv� %(JLN,�,IJG�A.(�J�,4_a � c�1
SUBMIT A COPY OF STATE LICENSE # .1 c..-QO � `-C �__
YOUR STATE LICENSE
AND CERTIFICA7'E OF ADDRESS��
INSURANCE PHONE Ce c�I� ��^ LC�-i
PROPERTY TYPE SINGLE FAMILY ION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH ❑ ROOF
❑ DECK 8'�IDING
❑ SWIMMING POOL
TYPE OF WORK: � NEW HOME CONSTRUCTION ❑ ADDITION
,�'1CIAINTENANCE/REPAIR ❑ R�MODEL:
DESCRIBE WORK BEING DONE:
S1ZE OF 7MPROVEMENT
TH
CITY
Permit No.: �0 � � � � �
Received By: �
i���a� �`� � $ � � i c
hdde�evSi hc. cow� •
STATE Uv1�"ZIPs��o�- i
EAD CERT NUMBER I U f�'F 1�. !U� `l'—' �
CITY�fii<-8 C�(1�-!G!D STAT�"1N ZIP �SD�
FAx 1P5�- � 8 3-R05 b
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
G
� � , _
HEIGHT
FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIUHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
inyl �$offit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other �Fascia and proposed project.
2. Two seu of construction plans
WINDOWS 3. Energy Calculations
IIv FX[STING OPENINGS ❑Yes ❑No LOCA; ION JF 'W'P�IDOWS FOR WINDOWS - PROV?DE U-VALUE AND
OR FOR NEW OYENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYYE 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 $ � I U O- a� OCCUPANCY TYPE
Permit Fee $ "% See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ a�j' .� .001 times the total job valuation
Surcharge $ ��. ,�j .0005 x Permit V aluation Minimum $5.00
License Surcharge $ ,5 , U� $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$24 =$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ , Make checks payable to: City of Fridley Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL 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 w:tn the ardinances-a�d codes a. the ity of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicati for a ermit an ork is not to start without a permit on site• that the work will be in accordance with the
approved plan in the case of all k w' h re ' vi w a d approval of plan��� � �� 1�
SIGNA'fURE OF APPLICANT PRINT NAME �J l�W� DATE � �
APPROVAI. INSPECTOR SIGNAT �
PLEASE NOTE: SEPARA ` I S ARE RE UIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK