P - 47806Building
Inspections
763-572-3604
763-502-4977 FAX
DATE s
SITE ADDRE S ��
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTtVE I-1-2011
Permit No.:
Received By:
Date Rec'd:
YOUR E-MAIL ADDRESS �J � �� p���C f� 1���,�S,�J ��. � M'�
�
�WNER ❑CONTRACTOR
NAME: K I P rCC,A-�Q �.�}-Lf'fi�/�C'i�L_
ADDRESS: ,j 7 �I % d¢L`f�„JQ,¢ T7 n N�C CITYf�/!� C,` c�
PHONE: "7 / -; .-7,� ;- � � y.�(o � STAT�i(% ZIP SJ`�% z /
NAME:
STATE LICENSE �/
ADDRESS:
PHONE
�L�FrYNGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
L�1v1AINTENANCE/REPAIR
DESCRIBE WORK BEING DONE: �I�
OF
r�-- Ff U
LEAD CERT NUMBER
CITY
FAX
`�4�OOF
,�SIDING
❑ SWIMMING AOOL
❑ ADDITION
❑ REMOQELING
= %�OFLC l� ?nn ,C /_
�-�.,�v � n WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES �5$ ��,qw �j �OUSE & GARAGE
GARAGES � 2 ❑ ATTACHED GARAGE
PROPOSED SIZE: O �DETACHED GARAGE
PROPOSED HEIGHT:
SIDING
�
❑ Aluminum
❑ Other
❑Softit
❑ Trim
❑ Fascia
❑ DRAIN T1LE
❑ OTHER
HEIGHT
STATE ZIP
,a��t���E;C`/�=�:'
SQ FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
WINDOWS . 2. Two sets of construction plans
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS 3 Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS — PROVIDE U-VALUE AND
OPENING CHANGES & MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED
NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING TNE COST OF LABOR AND MATERIALS:
NG THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �
Permit Fee OCCUPANCY Tvn�
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ a
$
$
$
$
$
$
$
$
$ . . _ .
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 a able to: Cit of Fridle Attach Sti ulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D 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 or a permit and wo k.is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of a or whic re 'r
SIGNATURE OF APPLICANT , } roval of plans.
APPROVAL INSPECTOR SIGNAT NT NAME IZI I.� Q , PA.1 yy,pr�',£2DATE�6 g/ZQ ��
.�.:,�:ax'i��7.'.T'�'.A.�'i['1f5''f.tt'f.ri•`„rm.i+. e;i.�`:�_ ... :. ...: . ... .......... .