P - 46287Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � ' �� � L �
SITE ADDRESS �
TFi1S 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 OF FRIDLEY
EFFECTNE 1-1-2011
CI OWNER
NAME: V! `�
ADDRESS: Y�3C
PHONE: ��DJ -J �
Permit N
Received By
,
L)ate Rec'�l:_
� YOURE-MA[LADDRESS (.�uDl�l Y����C�I�I�%� • CO� � ••
�F. bYz.l�t%
�ONTRACTOR
' ��
NAME: Y 1 S(U CX'hP�''f F�LS Yh[ J/i f1'
STATE LICENSE # o2'O`S�J��S �� LEAD CERT NUMBER ,1
ADDRESS: IO�QJ �� �' �. �j(�17� C CITY�
PHONE ��'31S '���� FAX %ix� -c3IS -
GLE FAMIL EW CONSTRUCTION SIZE
O TWO FAMILY/NEW CONSTRUCTfON STORIES
O ADDITION ❑ GARAGE/SHED ❑ WINDOWS
O BASEMENT FINISH �ROOF ❑ DRAIN 7'ILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
� NEW HOME CONSTRUC170N ❑ ADDITION
❑ MAINTENANCF../REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: ¢�- - f�(��{ Z �/}j t� �
S1ZE OF IMPROVEMENT ___ LENGTH WIDTH
ROOFiNC �`
NUMBER OF SQUARES D • �
GARAGES
PROPOSED SIZE:
PROPOSED HF.IGHT:
IDlN
❑ Vinyl
❑ Aluminum
❑ Other
O HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
O DETACHED GARAGE
ATE/���ZIP -�S � Z
�/'11(.y�i
STATE / ut/ZIP S�s3�,
FT
BASEMEi. t REMODELING SUBMIT•
1. Existing Floor Plan .
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTTON INCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTTNG OPENINGS ❑Yes ONo 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 $ .��� =" 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 $ i� $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 _ $ S �„ Make checks aavable to: Citv of Fridlev Attach Stinulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTTL PROCESSED
I hereby apply for a building permit and a owledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances c the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application f a and work is not to start without a p rmit on site; that the work will be in accordance with the
approved plan in the case of al uires review and a proval of p . �
- _� ����.�;�� � � �s� �.�g: � 9-//
APPROVAL iN5P CTOR SIGNA'
PLEASE NOTF.� SRl