P - 41199Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ��2�� � �'
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-20] 1
YOUR E-MA1L ADDRESS d �ahl,pGro
_ _ . , . _ ..__ --r—
�OWNER ❑CONTRACTOR
rr.aME: .i� �,rvr a Y� ��u n �
ADDRESS: RS�(o�1 �}'y�� CITY
PHONE: 7ip3— S / % " �5P ?j %
NAME: _
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: CiTY
PHONE
�'SINGLE FAMILY/NEW CONSTRUCi'IOl�i
� TWO FAMILY/NEW CONSTRUCTION
❑ ADI?IT10N ❑ GARAGE/SHED
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
Q SWIMMING POOL
TYPE OF WORK: (❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR �'REMODEL
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT_
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ HOUSE ONLY
❑ HOUSE & GARAGE
L] ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS,,�Yes ❑No LOCATION OF WtNDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES & �S�m �--
TYPE OF WINDOW TO BE INSTALLED NUMBER OF \
FAX
SIZE
STORIES
WINDOWS
❑ DRAIN TILE
❑ OTHER
Permit No.: �� �''`d��l ��
Received By: � t�w
..,,, ;�; : . � �i��l
GC.�I QD � Cd-n7
STATE
STATE ZIP
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTfON 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:
�j�-S�, d� ^(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VAL A�I'ION $ - � OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ ` ��r. � s
$
$
$ �- S
$
$
$
$
$
$ �—
$ j
See Back Page for Fee Schedule
65�/0 of Building Permit Fee
.00'1 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 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 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 withaut a permit on site; that the work will be in accordance with the
approved plan in the case of 11 �ork wh'ch equires review and approval of p ns
S[GNATUKE OF APPLICANT p_� PR[NT NAME �ebora.l�, DaG� l DATE ���'� ��
APPROVAL INSPECTOR SIGNATURE