P - 36669Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �� � �
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
DESCRIBE WORK BEING
BUILDING
RESIDENTIAL APPLICATI4N
CITY OF FRIDLEY
EFFECTNE 1-1-2011
❑ OWNER
ADDRESS
PHONE:
_ YOUR E-MAIL ADDRESS _
, A.n� C,�urr�J S
�CONTRACTOR
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CITY
Permit No
Received By:�1l��
Date �c�: � � � � � � �'�
5� f � '�
N.v�E: �vt,A��Nt-�N���e Fi,.�o (✓Li �tr�►�So -. _
STATE LICENSE ti gpa "[� � LEAD CERT NUME
ADDRESS: �%Sf/ GtNi i/�.1�/%l /�-� / �E CITY
PHONE �TG3 � �� O " '� ���
IJ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION
❑ ADDITION ❑ GARA(
FAX /dS �' '
SIZE
STORIES
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK D SIDING � OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
� MAINTENANCE/E2EPAIR ❑ REMODELING
RO FING ^
NUMBER OF SQUARES oc �
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
G Ka 0
❑ HOUSE ONLY
❑ HOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
❑Softit
❑ Trim
❑ Fascia
WINDOWS
1N EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENIIVG CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF V
�_STATE A'�.. ZIP��a
C.
at - -
vt_ ��S STAT.E�YI.✓ ZIP s�d1
�h � �['1 �'%
HEIGHT
BASEMENT REMODELING SUBMIT:
1. Existing Fioor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUC'ifON fNCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�SING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ !'�o � OCCUPANCY TYPE
Permit Fee $ , See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Stzrcharge $ .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ 5 $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 () Non Necessary (}
Total Due $ , Make checks navable to: Citv of Fridlev 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 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 all y:arl ,wkjch requires review and approval of plans. p.
SIGNATURE OF APPLICANT __ PR(NT NAME di1/C� �h TreL ff' DATE O�Is` / 1
APPROVAL INSPECTOR SIGNATURE