P - 47283Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �/�'�///
SITE ADDRESS �q�
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
��'�� �
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.:
Received By:
� .,, - � �
YOUR E-MAIL ADDRESS �DYif�i , y�'/�'�,7,� �t )in�,v ,�d,A � �iS.,yy/,�/ " �
❑ OWNER �CONTRACTOR
NAME:�y^j'C__ 6O f/�S
ADD�ss:�.s �,��`/a l�t�v i(/'.� crrx
PHONE: %�J`7� �r�a �
TATL��IP 2SS�Iv3a
STATE LICENSE #���`���/ �� LEAD CERT NUMBER�/�`%�`�j'7/�= �
ADDRESS:��% ��j� sjty� �� CITY_sj� /'��U STATE�IP�SLB"i
0
SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY�NEW CONSTRUCTION
FAX
SIZE
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�8`MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: /GG�A�Q,C� � �/�� �/d�s.
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
� wtNDOws
❑ DRAIN TILE
� OTHER
FT
BASEMENT RFMODEi IN 4i BMIT�
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS. & POR HES BMIT�
❑ Trim 1. Site Plan/Survey showing the existing structutes
❑ Fascia and proposed project.
WINDOWS 2. Two sets of constructwn plans
IN EXISTING OPENINGS J�Yes ❑No LOCATION OF WINDOWS 3. Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS — PROVIDE U-VALUE AND
OPENING CHANGES & p 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:
USING THE 1997 U.B.0 FEE SCHEDULE)
fOTAI. JOB VALUATION $ �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
$
$
$ '� �—
$ �� (� �J�—
$
$
$
$
$
$ ,�a
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: Citv of Fridlev ArrA�
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 des of t City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a e't an or is not to start without a permit on site; that the work will be i accordance with the
approved plan in the case of all and approval of plans�/� �� �/
SIGNATURE OF APPLICANT PRINT NAME !�%(atiC. /5�/G/`Cf'J'/�K_ DATE v%d
APPROVAL INSPECTOR SIGNA
PLEASE NOTE: SEPARATE A RE UIRED FOR PLUMBING, ELECTRICAL AND MECHAAIICAL WORK
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