P - 47726Building
Inspections
763-572-3604
763-502-4977 FAX
DATE /�� � / ' �J
SITE ADDRESS _
TH[S APPLICANT [S
BUILDING
Permit No.:
RESIDENTIAL APPLICATION Received By;_�
CITY OF FRIDLEY Da�D'c1��N
EFFECTIVE 1-1-2011 �
YOUR E-MAIL ADDRESS� !�'I/��1 ��✓� �� ��'�� �" , Lo�^
`�OWNER C3C�ONTRACTOR
PROPERTY OWNER/ NA�tE:
TENANT qDDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING �
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:_
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
O Other
NAME: G✓•/I
ia�
STATE LICENSE #���' �.a� �� LEAD CERT NLIMBEP
ADDRESS: �6..� � /cnh'�� �Y>�� CiTY�
PHONE GSj '%�� II `] � FAX �s,� i
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WiNDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
HEIGHT
STATE Z[P
ATE�YZIP ����`�
FT
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2. Proposed floor plan
3. List of structural 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 WINDOWS — 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 $ 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
$ `�� • LS
$
$
$
$ .�
$
$
$
$
$
$ o , r�-
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: City of Fridley 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 I understand this is not a
permit but only an application for a per it 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 al] worl ich re uir�eview and approval of plans�. -�-�
SIGNATURE OF APPLICANT PRINT NAME /�'� l7 ��.�y� 2 DATE .Ju`` ��l �,�I
APPROVAL INSPECTOR SI URE