P - 35179Building
Inspections
763-572-3604
763-502-4977 FAX
DATE__ �!L /
� �
SITE ADDRESS �
THIS APPLICANT [S
BUILDING
RESIDENTIAL APPLICATION
❑ OWNER
PROPERTY OWNER/� N,4ME:
TENANT �.._
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEING
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
NAME: � L2r.Gl�/(;���(
STATE LICENSE #��
ADDRESS: ,/��� � ��
PHONE �%%� �— ��Z ��
LEAD CERT
CITY
�SINGLE FAMILY/NEW CONSTRUCTION ' SIZE
0'fW0 FAMILY/NEW CONSTRUCTION STORIES
❑ ADD�TION ❑ GARAGE/SHED ❑ WTNDOWS
❑ BASEMENT FINISH ��ROOF ❑ DRAIN T1LE
❑ DECK '�SIDING ❑ OTHER
f❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCElREPAIR ❑ REMODELING
ROOFING
NUMBER OF SQUARES �.. �
GARAGES
PROPOSED SIZE:
PROPOSED NEIGHT:
S ING � u����
� Vinyl'' (/ � l
❑ Aluminum
� Other
r
❑ HOUSE ONLY
�-IOUSE & GARAGE
�O ATTACHED GARAGE � `
❑ DETACHED GARAGE 1
� SS
�,°�o�� (�9 0 �
❑ Trim �_
�ascia Q� � � j
� �
+�
Permit No.:
Received By:
Dat��d;
A
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structurai members to be used
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
L Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction pians
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WMDOWS — 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, INCLUDI1vG THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION $ 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
�.�il � � --
r
� � ,il
�
"' I.
�s�
�:�i_I'��'r—�
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 payable to: City of Fridley
Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL1D UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge that the information above is complete and accurate; that the work will be in
conformance with 'the ordinances and codes of the Ci of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit rlis,,not rt without a permit on site; that the work will be in accor nce with the
approved plan in the case of all o�vvhi requir re � w an provai of plans. �%/ �-�-��,�
SIGNATURE OF APPLICANT JNT NAME�r l�,r ( t° �'/ 5�if(Al/Y DATE
APPROVAL INSPECTOR S[GNAT RE lL%l -