P - 48148�
BU11C�111g ✓
Inspections
763-572-3604
763-502-4977 FAX
DATE I�- I��OI l I
SITE ADDRESS S S '�j
THIS APPLICANT 1S:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 11-2011
YOUR E-MAIL ADDRESS
3'� �-. w�.
❑ OWNER �CONTRACTOR
NAME:_ •I I Q� � �, I rni-�
ADDRESS: � � �� �I , /�.�,
PHONE: � � � " R� D ' �p (JJ��
NAME: GiMStf'y1 /p l,e,�,�n��
STA7E LICENSE # �lo� 1 � �6
ADDRESS: I� 7> O iT ,ZQYy�: i� E-
PHONE �S I — � ��I
� SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH � ROOF
❑ DECK ❑ SIDING
Permit No.: o� �( i��}� Q'�
Received By:
Date R�' . ..� �� � � � ��
►'«.
ATE�ZIP.
CERT NUMBER EXP:
CITY � STATE�NZIP�
FAX --
SIZE
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROV$MENT LENGTH WIDTH
R N ❑ HOUSE ONLY
NUMBER OF SQUARES � S ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
O Aluminum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ DRAIN TILE
❑ OTHER
�
BASEMENT REMODELING Si1RMiT•
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit SIDING/SOFFITlFASCIA ADDITIONS. & PORCHES SUBMIT:
❑ Trim REMOVED? ❑ YES O NO �• Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans °-
WINDOWS 3. Energy Cslculations
IN EXISTING OPENIIJGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENIidGS-DESCRIBE SIZE OF MANUFACTURE STTCKER ON WINDOW.
OPENING CHANGES &
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_ $ __ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Suroharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
$ °t'1 ? �
$
$ L!
$ l
$
$
$
$
$
��
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: Cityo uf 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 p rmit and work is not to start without a permit on site; that the work will be in a cordance with the
approved plan in the case of all � c hic uires review and approval of plan I ,�I /
SIGNANRE OF APPLICANT PRINT NAME �ditvt �J �GN�tn�rt DATE ���O
APPROVAL INSPECTOR SIGNA ' '
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