P - 47351Building
Inspections
763-572-3604
763-502-4977 FAX
DATE (�-, — /� — //
SITE ADDRESS �
THIS APPLICANT IS
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-i-2011
Permit No.:'���'a b� 3 �
Received By: �
���e��` I `i ��
YOUR E-MAIL ADDRESS ��t1.t )C, �- ���j�d GUJ"�
❑ OWNER '�ONTRACTOR
rKUPERTY OWNER/ I N,q�E: �
TENANT
ADDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
�
PHONE: �%3 ' S"�! - s�,3,�
CITY
NAME:��/G^7LT�/�! �oriD/M�IY
STATE LICENSE # 1 1� `)Yo LEAD CERT NUMBER
���t_''
. .,���r. �o T� — oc+
SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
B'i�vIAINTENANCE/REPAI R
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES 2! • 'J,3
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
FAX
S[ZE
STORIES
r� xvvr ❑ DRAIN TILE
❑ SIDING ❑ OTHER
❑ SWIMM[NG POOL
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
f3Soffit
�im
ascia
LOCATION OF WINDOWS
HEfGHT
STATF%1N ZIP �j I,3Z
ATEM� ZIP�
FT
BASEMENT REMODELING SUBMIT
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING 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.
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 $/o �p ,cs� 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
$ ��
$ .
$ �,
$
$
$
$
$
$
$
$
See l3ack Pa�e for Fee Sche�I„iP
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
lations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 acknowledge that the information above is complete and accurate; that the work wili 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�ermit 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 whi uires review and approval of plans.
SIGNATURE OF APPLICANT ,� PRINT NAME �'lorfnl ,N.•�f.:� DATE / !/
APPROVAL INSPECTOR SIGNPfTURE
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