P - 46817Building
Inspections
763-572-3604
763-502-4977 FAX
DATE / � / S � (
SITE ADDRESS ��!
I THIS APPLICANT IS:
i PROPERTY OWNER/
TENANT
I
I 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
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER 61CUNTRACTOR
NAME: �� % �,� � ��- �G �
ADDRESS: CITY
PHONE: 5 q� �'� �'
NAME:
�
Permit No.:
Received By: "v ��
D����d��' �� � �Q1�
ATE ZIP
STATE LICENSE # .� n �'? ���' � Oc> LEAD CERT NUMBER ���^ �,5' � $�o� ��
ADDRESS: ``S'� CiGj / �r% �^ L Gj� ! � � . CITY /�!'y � G.�$�ATF��1%LIP S.S=.��
PHONE 7ti� -�7�5/��9.� G� F,ax �G3 �- 7 � y'— � � � �
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK �G ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:�� S �'�� /j ��,s p � Gj �,��� �
. .
SIZE OF
, ROOFING
', NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SID
myl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WiNDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural 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 plans
3. Energy Calculations
FOR W[NDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(U�SI� G THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�`TpQ(� . p� 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
$
$ �
$ �, 17--
$ �-?j()
$ "
$
$
$
$
$ � �1 � � Z�
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
THIS IS AN APPLiCAT10N 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 work which re uires r view and approval of pla� �� > ti / /`
SIGNATURE OF APPLICANTh���ii� �� ��. � PRINT NAME_1/ sn,� j /%'INess�! , � DATE �! / �/ /!
APPROVAL INSPECTOR SiC; �fu�