P - 43786Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_ �] cT�� b e
SITE ADDRESS �
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 I-1-2011
1 YOUR E-MAIL ADDRESS
"— f�v 111� � �;d�� 1"�1�i
�OWNER ❑CONTRACTOR
ADDRESS: � 3O� S
PHONE: � lp3 ' S ! 4 "
NAME:
STATE LICENSE �!
ADDRESS:
�% �V �. CITY %—V'i(�!-F
��1�( 3_3c�o- g7oco �
CERT NUMBER
PHONE FAX
�SINGLE FAMILY/NEW CONSTRUCTION SIZE_
'❑'['WO FAMILY/NEW CONSTRUCTION STORI]
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
DESCRIBE WORK BEING DONE:
ROOFING
NUMBER OF SQUARES ��
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
HOME CONSTRUCTION
IWINDOWS
IN EXISTING OPENINGS ❑Yes ONo
� OR FOR NEW OPENINGS-DESCRIBE SIZE OF
� OPENING CHANGES &
� TYPE OF WINDOW TO BE INSTALLED
Permit No.: �6��'C�Oi �� �
Received By: -
Daf���' � � � � � � � � �
ATE�ZIP S S 421
CITY STATE ZIP,
�tOOF ❑ DRAIN TILE
� SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
`�HOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
OF
BASEMENT REMODELING SUBMIT•
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION RJCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. 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 $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
� —1� 1,`�_
$
$ G-�
$ �
$
$
$
$
$
$
$ � �
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: City of Fridley Attach
THIS [S 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 o 1 wor hich equire review and approval of plans. '�` j^ 1
SIGNATURE OF APPLICANT„�iv�,es ��CG„RJ�-�� PRMT NAME C.j� V��t I�UIC\�P1� � Vc� DATE � C�pbeV {'�t� �� 1 I
APPROVA� INSPECTOR SIGNATU �—