P - 40830Building
Inspections
763-572-3604
763-502-4977 FAX
DATE��
SITE ADDRESS �
THIS APPLICANT IS
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDFtESS
�
,�e..o �J v.� N� f'.� iU�,
� OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: ,U � fi�C,e` F�<SE"�
TENANT p,DDRESS: CITY
PHONE: �� 3� Z.I �— y.3,3 2
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Permit No
Received By:_
Da't�-R��'�'�. �
STATE ZIP
CONTRACTOR N.aME: 72.�qp�SmyriG %�v�e �Inv G.h, �LC..�
SUBMIT A COPY OF STATE LICENSE # �.� ���� J LEAD CERT NUMBER /A/A%' ^ I�� �S-3 —
YOUR STATE LICENSE J
AND CERTIFICATE OF ADDRESS: f��._s�� �E?•-�rccp � �✓� CITY �0� i-, P STATE/J!!n
INSURANCE PHONE �/ 2' ���".�,� �� FAX GSI— 3 7`� �%,3 v��
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
,�TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ,�(,WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADD[TION
❑ MAINTENANCE/REPAIR .�REMODELING
DESCRIBE WORK BEING DONE: /�P�D /�L �� � C-�l+r!
OF
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT;
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS �,iYes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYAE OF WINDOW TO BE INSTALLED�
LENGTH WIDTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
O DETACHED GARAGE
❑Soffit
Cl Trim
❑ Fascia
LOCATION OF WiNDOWS
:i NUMBER OF WINDOWS_
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION RJCLUDING 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:
SING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $���� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
_$ �,3 -L�r See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ f�j .0005 x Permit Valuation Minimum $5.00
$ ,�(SC7 $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
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 Fr' y and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application f a permit and or is n t o start without a permit on site; that the work will be in accordance with the
approved plan in the case of � ork ich ev nd approval of plans. /��� �
SIGNATURE OF APPLICANT PRINT NAME �,�! � / 7iC��t7 DATE �/Z %/ /I
APPROVAL INSPECTOR SIGNATURE .L�/ .i