P - 46478Building
Inspections
763-572-3604
763-502-4977 FAX
DATE___j_ �_
r-
SITE ADDRESS
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
BUILDING
RE SIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECT(VE 1-t-2011
YOUR E-MA1L ADDRESS
❑ OWNER
ADDRESS:_!��� �� CITY
PHONE:
STATE LICENSE #
ivi c Y+ c.J i �
INGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK:
DESCRIBE WORK BEING
OF
ROOFING
NUMBER OF SQUARES _
I GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
_ 1 v,:..�� l �
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS es ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WTNDOW TO BE INSTALLED
❑ GARAGE/SHED
❑ ROOF
❑ SIDING
❑ SWIMMING POOL
❑ A[2BIT,
LENGTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
� ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
Permit No.:_�} ��� �
Received By:
Date��L�I:�Q� �. a �o��
STATE {^'1!/�IP ��.��
CERT NUMBER ' `�
CTTY C(>�CU ��-� STATEi"''�'�iP S J.��
FAX
SIZE
1L�Il��y.l
❑ DRAIN TILE
❑ OTHER
BASEMENT REMODELRJG SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of struc!ural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR W[NDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER 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 $� I ZC,�,.`%� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Contro]
Park Fee
Sewer Main Charge
Total Due
$
$
$
$ c'��Z„�
$
$
$
$
$
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 (P(ans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks navable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERM]T-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 es he City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but oniy an application f9r"a pe ' an work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case o�work r ' es 'ew and approval of pl ��
SiGNATURE OF APPLICANT �- � PRINT NAME �C ��l�t- DATE %,/--/��%/
APPROVAL [NSPECTOR SIGNATU /
Form Approvetl OMB NO 2070-0155 Expires 70/31/11
�,�/ EP/"'1 APPLICATION FOR FIRMS
� ENVIRONMENTAL PROTECTION AGENCY TO CONDUCT LEAD-BASED PAINT ACTIVITIES AND/OR RENOVATIONS
Important: This application is required by 40 CFR §745.89(a) for renovations and is a substitute for the letter,required by
§745.226(fK2) for abatement. Consult the instructions for firms applying for cenification to conduct lead-based activities or renovations.
For abatement activities, persons seeking individual certification should use the Application for Individuals instead oi this form. Please
fill out all sections. Type or print �esponses in black or blue ink only.
A. Application Type (select only one box from Option 1, 2, 3 or 4 of Section A)
1. IOption 1: Renovation. Repair, and Paintin4 (RRP and Dust Samplinq Technician) Firm Certification
Initial Recertification
or
Option 2: Abatement (Abatemen
Initial Recertification
Qor Q
Initial Recertification
O°f �
List abatement jurisdiction(s):
Renovation, Repair and Paintinq Firm Certification
Abatement Firm Cert�cation ($550 for �rst jurisdiction and
$35 fo� each additional jurisdiction — list jurisdiction(s) below)
Combination AbatemenURRP Firm Certification (a550
for RRP and one abatement jurisdiction, S35 for each
additional abatement jurisdiction — list abatement jurisdiction�s) below)
1) ($550)2) (5585)3) (3620)
(Please note, if applying for more than three jurisdictions add an additional $35 for each jurisdiction and list them on a
separate sheet of paper)
3. Option 3: Amend Existina Cenification
QUpdate firm information (no fee required)
QAdd abatement jurisdiction (S35 per abatement jurisdiction)
List abatement jurisdiction(s) being added to your existing certification:
1) ($35) 2) ($70) 3) ($105)
or
4. Option 4: Reolace Certificate
Q Replace Certificate (S15)
B. Enter total application fee 3
Note 1: See instructions for additional fee information and examples of required fees.
Note 2: If you are a federally recognized Indian Tribe seeking cert�cation as a firm check yes in the question below and see Fees
Schedule in the instructions to determine fee requi�ed.
Yes Q No � Indicate whether you are a federatly-recognized Indian tribe seeking ceriification as a firm.
C. Applicant Information
Name of Firm: �
Business Address: �
Street
Number (Please no P.O. 8ox) City
Mailing Address:
(if different from above) Street Address, Suite Number
Name of Attesting Individual:
Last
�
City
� 1 ✓+� Ud
Uli
State
State
'G
Middle
Firm's Phone #: _1r��� � � /' �� ext #!: Atiesting Individual's Phone #: � w���7��0 / � ext.
Attesting Individua�'s E-mail Address:
^�
Zip Code
Zip Code
EPA Form 8500-27 (Rev 9I11) Page 1 of 2
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