P - 39391Building
Inspections
763-572-3604
763-502-4977 FAX
DATE `� / �a
SITE ADDRESS
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATI�N
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
❑CONTRACTOR
PROPERTY OWNER/ Na,tvtE: O� G'' �J�� �I� �'
TENANT ,r�DRESS: � �'� �
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF [MPROVEMENT_
L ADDRESS
crTV �r Y�'
Permit No.:
Received By:
Date R�'�`.► ��, ,,� �--,����
A'
NAME:�/ � ���f,tl r Cf Pr"r
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: CITY STATE ZIP
PHONE FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH .�;ROOF ❑ DRAfN TILE
❑ DECK ❑ SIDiNG ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
ROOFING
NUMBER OF SQUARES Y
GARAGES
PROPOSED S1ZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
� Other
WINDOWS
IN EXISTING OPENINGS �Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WMDOW TO BE INSTALLED
LENGTH WIDTH HEIGHT
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffif
❑ Trim
� Fascia
LOCATION OF WINDOWS
NUMBER OF
FT
BASEMENT REMODELING SUBMIT:
I. Existing Ploor Plan
2. Proposed floor plan
3. Lis[ of strucwral members to be ased
FOR NEW CONSTRUCTION fNCLUDtNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing s[ructures
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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB �ALUATION $ 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
$ �� �� �� 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 ( )
� I 1 P,.� Make checks aavable to: Citv of Fridlev Attach
lations
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 co of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but oniy an applicat' for a pe t and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case f a k w' Y uires review and approval of plans. �
SIGNATURE OF APPLICANT PRINT NAME �/ �1 �� h�� �, � DATE S�� � � Z ��
APPROVAL INSPECTOR SIGN U