P - 39333Building
Inspections
763-572-3b04
763-502-4977 FAX
DATE � ��
SITE ADDRESS W� �
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
Permit No.:
RESIDENTIAL APPLICATION Received By: j 1 a,�
CITY OF FRIDLEY Da�'c� � t� ������
EFFECTIVE i-I-201 F
YOUR E-MAiL ADDRESS �JCl c✓ G�C�+f �l(`l �'GL1C� �!%/yt /! • L p!!�1
� /�. /�1�r�<�.•, /�'! c 1 �'� 3 Z.. - -
❑ OWNER ❑CONTRACTOR
�
PHONE:
NAME:�
STATE LICENSE #
ADDRESS: � .�i�
CITY — /��C
� �
LE CERT NUMBE�R`y �� �--
CTTY �ll` . IT�i�
PHONE - J �' ` , FAX
SINGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRA1N TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/RE�AIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
ROOFING
NUM6ER OF SQUARES �_
GARAGES
PROPOSED S1ZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
O Aluminum
O Other
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAG�
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WiNDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
HEIGHT
STATFj!�,2ZIP
� .J � �' (C J " CJ—�3'CJ
AT�ZIP�S�
FT
BASEMENT REMODELING SUBMIT:
i. Existing F(oor 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 Caladations
FOR WINDOWS — PROViDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS I
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $!O � C�CiY� 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
$ �'"�. Z� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .00�5 x Permit Valuation Minimum $5.00
$ $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (P(ans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ f(� , � Make checks payable io: City of Fridtey Attach
lations
THIS IS AN APPLICATION FOR A PERMTT-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 permit and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in t�e case of all w which requires review and approva] of pl �ns,,.•
SIGNATURE OF APPLICANT PRiNT NAME CGL� LI��SC7iCJ DATE ���:�2C7(/
APPROVAL INSPECTOR SIGNATURE