P - 44111Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
SITE ADDR SS _
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:
DESCRIBE WORK BEING
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No. `/�l7 I I'Ud l l� 1
Received By: ��
�
:.�,
�.
� �:► : � T �. �..:,..
YOUR E-MA1L ADDRESS e�t�c.� �.�c�.�-rcrJti��ld�n • cv�.•�
❑ OWNER �'CONTRACTOR
NAME: C✓ v �� u 6�
ADDRESS:n S fi^
PH(1NF� /� � � •/ I �- (� �
CITY ("—/�
ATFiLI�,�Z[P,
NAME: r l n �
STATE LICENSE # G O LEAD CE T NUMBER
ADDRESS: � � CITY S Ct,.y( STATF/l_�j ZIPSile�
PHONE o� � Z�S ^-GX,�%S FAX �$( - 91 %— U��'i�.3
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILYMEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FlN1SH ❑ ROOF
❑ DECK �SIDING
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION O ADDITION
❑ MAINTENANCE/REPAIR �2EMODEL
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
SIDING �
❑ Vinyl ��
❑ Aluminum
❑ Other ��t
IWINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
�, OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
' TYPE OF WINDOW TO BE MSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATIONDF WINDOWS
NUMBER OF
❑ DRAIN T1LE
❑ OTHER
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structurai 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 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:
SING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ , C.`Y�U °Q 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
$ �(Q � � L5 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 (Pfans to MWCC for determination)
$ ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks aavable to: Citv of Fridlev 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 1 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 w w' requires review and approval of pl ns.
SIGNATURE OF APPLICANT �� PR(NT NAME �ie(!L `,,'�Q.L� DATE /t�i �/% /ZC�/i
APPROVAL INSPECTOR SIGNATURE °%`