P - 37233Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � ( �O —
SITE ADDRESS ��
THIS APPLICANT IS:
PROPERTY OW1vER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2011
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YOUR E-MAIL
ADDRESS: �� �rp � LtJt�.� I�: � � CITY�
PHONE: ��a.�� Z�S .- ��7%d 7�.�–S%�"%(iss
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Permit No.:
Received By:
ATE%���( ZIP J .5 �3
NAM�:_ f-j(?(/G✓ c; l43, 1.�66c_[�--
STATE LICENSE # LEAD CERT NUMBER
ADDRESS:> ���% (N<<S uv^t� �`� G'� CITY /`�/Ol-S STATE��'�•ZIPSST/Z
PHONE �D f Z,5�2 Z— CD �� �F Fq}{
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
iW CONSTRUCTION
CONSTRUCTION
❑ GARAGElSHED
❑ ROOF
❑ SIDiNG
❑ SWIMMING POOL
SIZE
STORIES
WINDOWS
❑ DRAIN TILE
❑ OTHER
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
' ❑ MAINTENANCE/REPAIR REMODELING
��� DESCRIBE WORK BEING DONE: YZ�' �%u- D Yy, C� ✓'G2M.0 �CrS�F��+* �`^' `'
I SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ❑ HOUSE ONLY
� NUMBER OF SQUARES ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS Yes ❑No
OR FOR NEW OPENINGS- ESCRIBE SIZE OF
OPENING CHANGES & 1w55
TYPE OF WINDOW TO BE INSTALLED�__
ALL FEES ARE BASED
TOTAL JOB VALUATION $
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Totat Due
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
� Fascia
LOCAT ON OF WIND WS
�} Cc SQ :.rt Cw-�
,��ocl NUMBEROFWINDOWS �
ow s w�+h c� /�s's (t516c fL () �j �'Q GY�
HEIGHT SQ FT
BASEMENT REMODELING SUBMIT:
1. 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.
VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
5 .°.1° OCCUPANCY TYPE
$ l� �,� (��► 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 �avable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERM]T-NOT VAL[D 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 Fr' ey and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and wor is t t start without a permit on site; that the work will be in accordance with the
approved plan in the case f all ork whic r ires revie d approval of plan/s � r/ / / `
SIGNATURE OF APPLICANT � N AME J`�U/�"� 1"�0 �` � DATE �r�b �I /
APPROVAL INSPECTOR SIGNATURE