P - 45474Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 7 J�" � �
SITE ADDRESS CI C�
TH[S APPLICANT [S:
PROPERTY OWNER/
, TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
1NSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BETNG D(
SIZE OF (MPROVEMENT_
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-201(
YOUR E-MAfL ADDRESS
�7f'' �� .
❑ OWNER �CONTRACTOR
NAME: C� �� �'Y.� � GE� J I-C�
ADDRESS:_ 5C ��_ CiTY
PHONE:
NAME:
C
Permit No.:��'� ��1 i �.G'
Received By: ��
D��'�:�� � ����
STATE ZIP
STATE LICENSE #�C��� 3C,3�� [,EAD CERT NLIMBER
ADDRESS: I�� �U /� r C��P,-1 C�r�� f� N � F CITY ,�t'�'tc� d�/ �' +' STATE J' ��IP
PHONE b ! 'L �' S �,t �! � /�7 � FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDRJG ❑ OTHER
❑ SWIMMMG POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
.. .� E'•�UL3 v
ROOFING �
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED__
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑So�t
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor ?lan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION RJCLUDTNG DECKS,
ADDITIONS, & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WRJDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WfNDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ �(j'C)._ � OCCUPANCY TYPE
Permit Fee
Pian Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$
$
$
$
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 Fridiey
Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 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 is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all r ' es review and approval of plan . `'� r I'
SIGNATURE OF APPLICANT PRINT NAME C�0.C� � f� C kS(��1 DATE /'��
APPROVAL INSPECTOR SIGN TURE