P - 35431Building
Inspections
763-572-3604
763-502-497? FAX
DATE � — L / � / /
SITE ADDRESS g�v
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 D(
SIZE OF IMPROVEMENT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS S G V) �Vl ' ,�
. �e N� �
❑ OWNER �CONTRACTOR
NAME:�
ADDRESS:
'� �
CITY
NAME: /��Val KeSTora rt orr Zr1C.
STATE LICENSE #�Z�J�'1 LEAD CERT NUM
ADDRESS: �I�Z y0 �/� CITY
PH�NE �I%�" 7o O —OC�9Z FAX %�.:
SINGLE FAMILY/NEW CONSTRUCTION S
TWO FAMILYMEW CONSTRUCTION S
❑ ADDiTION
❑ BASEMENT FINISH
O DECK
❑ �IEW HOME CONSTRUCTION
ROOFING
NUMBER OF SQUARES �_
GARAGES
PROPOSED SI2E:
PROPOSED HEIGHT:
SIDiNG
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ SIDING
� SWIMMIT
❑ ADDITION
❑ REMODELING
�❑ OUSE ONLY
HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Softit
❑ Trim
� Fascia
LOCATION OF WINDOWS
NUMBER OF
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
r
Permit No.: �
Received By: ���
�������-7 — n,�
STA'
�i
STATF.�IZIP S✓� Z
FT
BASEMENT REMODELING SUBMIT:
1. Existing Ftoor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing structures
and p�oposed project.
2. Two seu 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 AIVD MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 9. IO� � �O 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
i
.� :
��
�r..�7•
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 Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknow(edge that the information above is complete and accurate; that the work will be in
eonformance 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 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 al�% �o��whic e�l u�res review and approval of plansr ��� �_ �/
SIGNATURE OF APPLICANT i�P�fPY�►�iL�'Lr•• PRiNT NAME ✓ ff�D�CN Q� H'1 DATE
APPROVAL INSPECTOR SIGNATUR