P - 35962Building
Inspections
763-572-3604
763-502-4977 FAX
DATE� _/__`
!
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY' OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICAT� OF
INSURANCE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
�- YOUR E-MAIL ADDRESS
„ `� � 1 ,.
❑ OWNER
NaME: �v � � r � 4 I /�'
ADDRESS: CITY
PHONE:
NAME: /(/�o l� 1�.. ,.. �iC'7`//'r ,n/" c'
Permit No.:
Received By:
/ . ► �� • i •� � � �
r
ATE Z[P.
STATE LICENSE # �c3 �� �J'��% O p LEAD CERT NUMBER
ADDRESS: �� O�p ��?'7r/S ,G d.�! �° /v/� CITY c!� � 4.E',Ec STATE/�i►�,IP SS.�ai
PH9NB ?6� "? �f LI "�Q� 6 FAX 7L.� "%�Y'— �� 3�
PROPERTY TYPE �f SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION
PERMIT TYPE ❑ �DiT10N ❑ �G �AGE/SHED
❑ BASEMENT FINISH �'ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
SIZE
STORIES
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �^�' � � f c�lt� � ct
SIZE OF IMPROVEMENT LENGTH WiDTH
ROOFINC O HOUSE ONLY
NUMBER OF SQUARES �� „ ❑ HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
' 3IDING
i � Vinyl
O Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WiNDOW TO BE INSTALLED
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
❑ DRAIN TILE
❑ OTHER
�
�"i
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structurai members to be used
FOR NEW CONSTRUCTION MCLUDING 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 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 $ S, 7�..�� i°� _ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � � • 4�5
$
$ o
$
$ S --
$
$
$
$
See Back Page for Fee Schedule
65% of Building Pertnit 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
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 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 ork�h re �res review and approval of pl�anS- A/ /
SIGNATURE OF APPLICANT �- �' PRiNT NAME_ �%in'1 /v+'�����,,,,� DATE__� /� %�
APPROVAL INSPECTOR SIG URE '