P - 39999Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �
SITE ADDR SS � �l
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:
AESCRIBE WORK BEING D(
SIZE OF [MPROVEMENT__
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-I-2011
YOUR E-MAIL ADDRESS
OWNER ❑CONTRACTOR
NAME: ` /iLSh i ,/�t/�
ADDRESS: ��h:�^�,�tTj ,/�-Cl'^�CfTY
PHONE: '7i 7 -._
NAME:
STATE LICENSE # LEAD CERT NLJMBER
ADDRESS: CITY
PHONE
FAX
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION D S'iARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ;�-'ROOF ❑ DRAIN TiLE
O DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUC'TION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
ROOFING �
NUMBER OF SQUARES }��._�_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WIIVDOWS
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
Permit No.:
Received B�':�-
L�;�I,�eC�6 �=��_
7 �} �`L' Cl. %�G 6'�C'i . �r; i�t..
ATE_,��ZIP
ATE ZIP,
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION i1SCLUDING 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 ST[CKER 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
Pertnit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Contro]
Park Fee
Sewer Main Charge
Total Due
$ � �,. ��.�
$
$ � '�—
$
$
$
$
$
$
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 Bngineering
Agreement necessary ( ) Non Necessary (
Make checks pavable to: Citv of Fridlev
Attach Stipulations
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 cod 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 rm' 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 work w u�res review and approval of p1.a�.�!J 9
SIGNATURE OF APPLICANT �' PRINT NAME � (,�� /yJ �L/; �if.t� DATE �i �
APPROVAL 1NSPECTOR SIGNATURE T