P - 41747Building
Inspections
763-572-3604
763-502-4977 FAX
DATE f*��' �� —/ �
SITE ADDRESS � � "
THIS APPLICANT IS:
PROPERTY OWNERI
TENANT
I, CONTRACTOR
SUBMIT A COPY OF
I YOUR STATE LICENSE
AND CERTIFICATE OF
' INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
,,yOUR E-MAIL ADDRESS � /' �-`�:� �- � /
c����� � , � z,��:�i�-�
❑ OWNER �GONTRACTOR
NAME: _CC� _' G�''v ��
ADDRESS: Sfs'C� `— �✓ J��l"i"Z`� C(TY �2%�C�I�
PHONE: ipl.Z' ��L%�'" 3Z-'�'�
NAME: /C t�`I/�f _ i/L.- I f.� ���t ��w�f .i� G�i rr� t U t�1..,
PermitNo.:��'�� � }� ��
Received By: �'"� �
Date Rec'd: : " �'��
4� �� �`�� : �01�'�1
STATE.! �.C�ZIP
L C_
STATE LICENSE # ,��J_`L� j�j�;�- � v LEAD CERT NUMBER
ADDRESS: / � ��C�C �'..�G� CiTY -Cj�/<�+V �°� STATE/''�t,ZfP �. .�j�J
PHONE _ % L�J .j "- � ��r' -- .S�' %C� FAX
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH C] ROOF ❑ DRAIN TILE
❑ DECK [7 SIDING �-pTHER ^ ('i(,,¢� (��s EZ � i� �1
❑ SWIMMING POOL �
❑ NEW HOME CONSTRUCTION O ADD]TION
�4AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: L�i� G�(o � rs� �
SIZE OF IMPROVEMENT
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
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDO
�[ ✓✓`C'�.�1 '� 1 �G=�L..
Z� HEIGHT 5� SO FT
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2. P�oposed 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 proiect.
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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�� S� G� `��� 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
$
$
$
$
$
� :�
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 Sti
THIS IS AN APPLICATION FOR A PERM]T-NOT VALID UNT[L PROCESSEb
I hereby apply for a building permit and I ackno that the information above is complete and accurate; that the work will be in
conformance with the ord' ances and codes of th City o Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an a]ication a pe an o'� to rt withou a permit on site; that the work wilt be in accordance with the
approved plan in the ca all o c whi r r r' pproval pl�n -/) -%, /- �
SIGNATURE OF APPLIC _. ' PRINT� 0't` FI �Y/ �°� "` '�DATE � � r � r_ � �
APPROVAL INSPECTOR GNATURE . :. / A .
i:::��G"
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