P - 48374Building
�pections
3-572-3604
63-502-4977 FAX
DATE l� -- �� �'1I
SITE ADDRESS _
THIS APPLICANT IS:
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 1-1-2011
YOUR E-MAIL ADDRESS
❑CONTRACTOR
ADDRESS: .5 �%// %f i%1 5L` ��
PHONE: %I/'��,j%a— �I % 02.
STATE LICENSE #
ADDRESS:
LH'SINGLE FAMILY/NEW CONSTRUCTION
O TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: I o
DESCRIBE WORK BEING DONE:
ROOFING �
NUMBER OF SQUARES _�
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
HOME CONSTRUCTION
TENANCE/REPAIR
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ SIDING
❑ SWIMMING POOL
Permit No.:
Received By�
Da��' ci� �.� i� �` � 6 � �
G�pI��STATE �/'�i� ZIP�
LEAD CERT NUMBER
CITY_
FAX
SIZE
STOR[ES�r-
❑ WINDOWS
O DRAIN TILE
� OTHER
� ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WMDOWS
�
l;l�][el.fl�
ATE ZIP,
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCT[ON INCLUDiNG DECKS,
ADDITlONS. & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction pians
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 $ OCCUPANCY TYPE
I Permit Fee
'�: Plan Review
� Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ ` - --
7, 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 ( )
$ � �(y Make checks payable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby appty for a building permit and t 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 all work which requires review and approval of plans. -/ ` f
SIGNATURE OF APPLICANT `�(�$���is?� PRINT NAME �/j��G �,Q �'�' QrrE/Y DATE �a "(o � II
APPROVAL INSPECTOR SIGNATURE '
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