P - 45770Building
Inspections
763-572-3604
763-502-4977 FAX
DATE Cm — a ^ l
SITE ADDRESS _��
TH[S APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER ❑CONTRACTOR
Permit No.:
Received By:
Date Rec'd:
PROPERTY OWNER/ NAME: � T.� P����'C M. R t9'Z 1..,0..
TENANT p,DDRESS: 3� I (� Z �' {� V� dv � CITY °Frtd l� c� STAT��N ZIP �
PHONE: r
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
' TYPE OF WORK:
NAME:
��
STATE LICENSE # 5Y {�O � LEAD CERT l�ifMBER
ADDRESS: _� �I'�1 y� jn/��'� S�t , �i �, . CITY �W411 LQ�e STAT ZIP SS�d
PHONE �I �B j " '�I �rp' � %�Z � FAX S � � �
�-SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ W[NDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRiBEWORKBEINGDONE: j-euC�r— t�'F� (�t'
SIZE OF [MPROVEMENT LENGTH
ROOFING � �
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
HOUSE ONLY
HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Softit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCT[ON [NCLUDING 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 WItJDOWS — 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
I Permit Fee
' Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Contro3
Park Fee
Sewer Main Charge
Total Due
$ y7, ��'
$ �
$ . b
$ r
$ �c G�
$
$
$
$
$ ,�, _ .� �..
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 aavable to: Citv of Fridlev
Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-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 Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit a wor is not t start without a permit on site; that the work will be in accordance with the
approved plan in the case f a hich quire eview a approval of plans.
SIGNATURE OF APPLICAN NT NAME �GLk/�,�s" ��t ►^S I,C�, � DATE �" a- ^� I
APPROVAL INSPECTOR SI
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