P - 47261Building
Inspections
763-572-3604
763-502-4977 FAX
DATE //°
SITE ADDRESS � %�
THIS APPLICANT IS:
PROPERTY OWIVER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 11-201 ]
'�Y�UR E-MAIL ADDRESS F
_ `�fq � � �` �� �`��
❑ OWNER �(SNTRACTOR
NAME c�T�V�� Y/v`ES
ADDRESS: � :+ � ��! -
� � CTTY�1
PHONE:��?j � �— �oZ •��
NAME: � /e��4T� � t.'1'�,�'�
STATE LICENSE #�����j LEAD CERT
ADDRESS: J/(p (0' � �' f�
PHONE� 3— 9�` y�QO FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
B.'I`WO FAMILY/NEW CONSTRUCTION eTnurFe
PERMIT TYPE I❑ ADDITION ❑ GARAG
❑ BASEMENT FINISH �'1£OOF
❑ DECK ❑ SIDING
U SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:_ '�aQ./� �l�� .— ���� �
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES � ❑ HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
Permit No.:
Received By: � �
��'�e��°� � �. ����
STA
CITY�/��/� �( STA
❑ DRA1N TILE
❑ OTHER
HEIGHT
ZIP�' ��
FT
BASEMENT REMODELING SUBMIT
l. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMIT
❑ Trim REMOVED? ❑ YES ❑ NO � Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
WINDOWS 2. Two sets of construction plans
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS 3. Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS — PROVIDE U-VALUE AND
OPENING CHANGES & MANUFACNRE STICKER ON WINDOW.
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)
TOTAL JOB VALUATION $ nC C"iiPANf V TVDT�
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ f r See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ a� � .001 times the total job valuation
$ � .0005 x Permit Valuation Minimum $5.00
$ $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Pians to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ _ Agreement necessary ( ) Non Necessary ( )
$ r Make checks payable to• City of Fridley 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 pe it 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 k ch r` ires r}�ew and approval of pl ����
SIGNATURE OF APPLICANT k PRINT NAME_��� DATE �� �� ;�(i � r
APPROVALINSPECTORSIG