P - 35092�
, �.
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �• � • � /
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
BUILDING � , �' � perrnit �ro.: 2� ; � �;� ��''
RESIDENTIAL APPLICA ION Received By:
CITY OF FRIDLEY ����1 °� � ����
EFFECTIVE 1-1-2011
❑ OWNER
ADDRESS:JZS/D //�QO�C C�I
PHONE���J� SZaZ ' � � �.p � •
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CONTRACTOR NAME: � r�-�-l��A.D �
SUBMIT A COPY OF STATE LICENSE # ��F
YOUR STATE LICENSE —
AND CERTIFICATE OF ADDRESS:�
INSURANCE pHONE�P — �
PROPERTY TYPE SINGLE FAMILY N
D TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE D ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH �B�it00F
❑ DECK O SIDING
� SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
[TY �/l.�-u-�-«-i STAT�� ZIP � �
-� � ea e :
EAD CERT NUMBE � �
CIT�(.!XL'�c �^ STAT ZIP�Ol,
FAX [�PSI ��� �7v J �
SIZE
STORIES
� WINDOWS
� DRAIN TILE
❑ OTHER
DESCRIBE WORK BEING DONE: ..�l.i.Z� C� /C.. �
SIZE OF IMPROVEMENT TH WIDT HEIGHT S FT
ROOFING �IOUSE ONLY BA$EMENT REMODELING SUBMIT:
NUMBER OF SQUARES _� ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES O ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: D DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT: �
SID FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Viny] ❑Soffit ADDITIONS. & PORCHES SUBMIT:
O Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
and proposed project.
O Other . ❑ Fascia 2. Two sets of construction plans
WIlVDOWS 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 FEE5 ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
S TF�iE 1997 U.B.0 FEE SCHEDULE) .
TOTAL JOB VALUATION $ D��� • OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .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 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 Dne $ ��,�— Make checks payable to: City of Fridle.y Attach Stlpulat[ons
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 applicati r a permit and wo k s not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of ll w which quire re ie and a proval of pla s. �, / ��)/. //
SIGNATURE OF APPLICANT NT NAME � � U�I DATE Lf 6
APPROVAL INSPECTOR SIGNATU
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK
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