P - 47793Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ��/
SITE ADDRESS _iZ��
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
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-I-2011
YOUR E-MAIL ADDRESS
_ ❑ OWNER �CONTF
Na,t�E: r G�t
ADDRESS:� �_�
PHONE: _ C/� %rL'— _%C,/�1-1
NAME: ��7 S
STATE LICENSE #
ADDRESS: G�
Pun�.rF /_� l�Jr- % .`
CITY
�
�
Permit No.:
Received By, ' � � w
� —�> .
Date R�� � �� � �
ATE
LEAD CERT NUMBER
°�_CITY STATE�� IPS D��
Fa}c -7� 3— �7�3--26�G
YJ`S[NGLE FAMILY/NEW CONSTRUCTION S[ZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SW[MMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED S[ZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
�HOUSE ONLY
HOUSE & GARAGE
�TTACHED GARAGE
❑ DETACHED GARAGE
WIDTH HEIGHT
FT
BASEMENT REMODELING SUBMIT
1. Existing Floor Plan
2. Proposed floor plan
3. List of struc[ural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
WINDOWS 2. Two sets of construction plans
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS 3. Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS – PROVIDE U-VALUE AND
OPENING CHANGES & MANUFACTURE 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:
�/�(,i�ING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ `�� nCCIJPANf V �rvu�
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ j"15 ZS ---
_$
$
$
$ �
$
$
$
See Back Page for Fee Schedule
65% of Building Pennit 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 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 e_rmit is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of�3'C— hic re�iew and approval of p�yla �.� / /f %/'
SIGNATURE OF APPLICANT PR1NT NAME �//�%J` '�z���i>�'�'�i ATE C�/V /!
APPROVAL INSPECTOR SIGNATURE ,