P - 41757Building
Inspections
763-572-3604
763-502-4977 FAX
� DATE % / [ '
STTE ADDRESS
THIS APPLICANT IS:
PROPERTY OWNER/
' TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
BUILDING
RESIDENTIAL APPLICATI4N
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR E-MA1L ADDRESS
�
❑ OWNER
21�t Ge— �7r�1 Ck.s
PermitNo.: ����
Received By
Date���c�: °
Gti^ . (, -z'.
ADDRESS: �"{p .�I -• L �L .S! ��� C[TY �2I � L� t`/ STATELYI�ZIP .7S�I�Z'
PHONE: 7I / — � �/ ` �' �-� �
N,vv�E: I2 /AO� S
STATE C,ICENSE # ZO�C
GPj
PHONE �/ �" 9% p � r 3��
�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE � �DITION
❑ BASEMENT F[NISH
O DECK
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING
SIZE OF [MPROVEMENT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
'.:
D CERT NUMBER N A 1 --� �I � g�3`I
CiTY� i� STATE/�/✓ZIP .�✓7.�'�
FAx E'3� .� �9- 9�5'�/
❑ GARAGE/SHED � WINDOWS
❑ ROOF ❑ DRAIN TILE
O SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
�,REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes S�INo LOCAT ON OF WINDO S
OR FOR NEW OPENINGS-DESCRIBE SIZE OF I��,.S2,�vn-a.a.,�
OPENING CHANGES & � r
TYPE OF WINDOW TO BE INSTALLED CG�-GSS NUMBER OF WINDOWS ,/
F7'
BASEMENT REMODELING SUBMIT:
I . Existing Fioor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. 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:
� (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ Cv b C�' OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$ R6
$ �
$ �
$
$
$
$
$ ,
_ _ —_ _
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks pavable to: Citv of Fridlev
Attach Stipulations
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 L understand this is not a
permit but only an application fo a p 't a ork is ot to start without a permit on site; that the work will be in accor ance with the
approved plan in the case of al rk whi eq ' and approval of ptans. r— � I�y ���
SIGNATURE OF Af'PLiCANT INT NAME ��C.lL �y�.� D A T E � �
APPROVAL INSPECTOR SIGNA RE i
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