P - 35808Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ,7 � ��— (�
SITE ADDRESS bt!"� �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
iNSURANCE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2011
YOUR E-MAIL �.DDRESS
1� ���al�„
'L�OWNER ❑CONTRACTOR
Permit No.:
Received By:� � �ti�
Date R�e� � f ( � � � � ��
�
NAME: �o-t . 2 o.1��PI`c+�41 w �"'�
ADDRESS: ��'i6''"j A�l.,� �� (' CITY �� c� � STATE�ZIP �.S%3�,
PHONE: � �D3 � S � ( -- �°1,��
NAME:
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: CiTY,
PHONE Fax
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION
�TWO FAMILYMEW CONSTRUCTION
PERMIT TYPE � �DITION ❑ GARAG
❑ BASEMENT FINISH L�eROOF
❑ DECK �SIDING
❑ SWIMM
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION
'�MAINTENANCE/REPAIR
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES � �
GARAGES
PROPOSED SIZE:
PROPOSED NEIGHT:
IS DING
�Vinyi � �F'OD
❑ Aluminum r""""
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
S[ZE
STORIES
?/SHED ❑ WINDOWS
� DRAIN TILE
❑ OTHER
NG POOL
O ADDITION
❑ REMODELING
❑ HOUSE ONLY
�C[-IOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Pascia
LOCATION OF WINDOWS
NUMBER OF
STATE ZIP,
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed 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 project.
2. Two seu of construction plans
3. Energy Calculations
FOR WINDOWS – PROVIDE U-VALUE AND
MANUFACTURE STICKER ON W(NDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING 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
$ `7 `� ,'L5 See Back Page for Fee Schedule
$ 65% of Building Pennit 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 Fridlev Attach
THIS [S At�f 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 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 of all wqt�C�� r ires review and approval of pl�s, ,
SIGNATURE OF APPLTCANT f/� ° PRMT NAME l�� �a �+-oJ DATE 7– � 7 �/
APPROVAL INSPECTOR SIGNATURE