P - 35770Building
Inspections
763-572-3604
763-502-4977 FAX
DATE I l�
SITE ADDRESS _�D
TH[S 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 D(
SIZE OF IMPROVEMENT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-201I
Permit No.: � � � � � y� �
Received By: '
Date R�' q
RC.
YOUR E-MAIL ADDRESS Gri� cci��cs�t�rlr�e-� �kg�
; � nr£
❑ OWN R �ONTRACTOR
NAME: � �h-CJ
ADDRESS: �D� � �7� !�✓�ti1 /I/C/� CITY � ;
PHONE: �� J T4I 1 � l��
NAME: �JI�Y'� to,/7G�J � �.L.G
STATE LICENSE # 2�nr7 D /. LEAD CERT NUMBE '
ADDRESS:/� EJ• /��r Ik- F�' fy,� r,_ �� CITY ��i
PHONE
FAX
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
� MAINTENANCE/REPAIR ❑ REMODELING
ROOFING
NUMBER OF SQUARES _' �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
O Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
�. � v�
❑ HOUSE ONLY
�HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
� Fascia
LOCATION OF WINDOWS
NUMBER OF
HEIGHT
,�7� Ld�
ATE ZIP_
�
_STAT ;
BASEMENT REMODEL[NG SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTfON 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 STICK�R 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
Fir� Surcharge
Surcharge
Licens� Surcharge
SAC Charge
Curb Cut �scrow
Erosion Con�rol
Park Fee
Sewer Main Chax�e
Total Due
$ Cll.��'
$ ,
$
$
$
$
$
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 pavable 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 ordina,nces and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatiorr for rmit 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 which requires review and approval of pla %�
SIGNATURE OF APPLICANT PRfNT NAME �� G��'1 DATE �/ � J
APPROVAL INSPECTOR SIG URE