P - 47782Building
Inspections
763-572-3604
763-502-4977 FAX
, DATE ^ % � "
SITE ADDRESS
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
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❑ OWNER
rxurr;xTY owNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
NAME:
ADDRESS
PHONE:
NAME: �
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
_ YOUR E-MA[L ADDRESS
�CONTRACTOR
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STATE LICENSE # Z�Q uS 2/ 2--
LEAD CERT NUMBER
ADDRESS:f I ! f � Z¢A ( �vi � � ,� CITY �titQ
PHONE � � � � iL � O�� � FAX� � � S� I
�,INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILYMEW CONSTRUCTtON cTnurcc
u r�uvi i iv�v ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH I�tOOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
R.CMAINTENANCE/REPAIR ❑ REMODELING
3:--�v--? s 6 �l �. � �t�...�c.., n_�. //1�1 ,
ROOFING
NUMBER OF SQUARES �
GARAGES
POSED SIZE:
PROP ED HEIGHT:
SIDING
❑ Vinyl
❑ :4k mum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NE PENINGS-DESCRIBE SIZE OF
OPENING CHAN &
TYPE OF WINDOW TO BE INSTALLED
LENCrTH ' �xirn�ru
❑ HOUSE ONLY
"'B'F-IOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
O Fascia
LOCATION OF WINDOWS
NUMBER OF WINDnWS
Permit No.:
Received By:' ' "�
Date ''� � ��
IN
STATE ZIP
ATF 1LrLZIP
FT
BASEMENT REMODELING SUBMIT
1. Exis[ing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDING 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 WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
E+LL r �.�� .�K� BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TVPF
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$
�� r
�'
rT�
��71
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 Stipulations
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 Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit 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 wo hich requires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME�p���' '�.> 0�.3 �' /,��,N DATE Co l 3 �(
.
APPROVAL INSPECTOR SIGNATURE i