P - 35114Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_ '� �;
SITE ADDRESS �
TH[S APPLICANT IS
PROPERTY OWNER/ I N
TENANT
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEING D
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-20ll
YOUR E-MAfL ADDRESS
❑ OWNER �CONTRACTOR
PHONE:! (iD � " � I CQ — � `'1 "�`'�
NAME:�''�o�.i'`t �..r �t� �2. '
STATE LICENSE �
ADDRESS: � � �
PHONE ��— �L`� �-- �� �
O SINGLE FAMILY/NEW CONSTRUCTION
O TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION �ARA(
❑ BASEMENT FINISH ROOF
❑ DECK SIDiNC
❑ SWIMr
❑ NEW HOME CONSTRUCTION
❑ MACNTENANCE/REPAIR
ROOFING
NUMBER OF SQUARES �_
GARA.GES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENWG CHANGES &
TYPE OF W[NDOW TO BE INSTALLED
Permit No.:a, (}� ��
Received By: ' °
Date�t��: ��� �, ���
�U � CITY �r �r,� ��
�" �'? .�.... `.1�0. ��
LEAD CERT NLIMBER
k�ttS� ,��CITY_���„'�'
1 F,ax �r,�� �-I,�11--
SIZE
STORIES
:/SHED ❑ W[NDOWS
❑ DRAIN TILE
� OTHER
NG POOL
❑ ADDITION
� REMODELING
O�' �+r. S1t�..'�l.c,. �:,��
WIDTH HEIGHT
`�1 HOUSE ONLY
O HOUSE & GARAGE
`J�ATTACHED GARAGE
❑ DETACHED GARAGE
OSo�t
O Trim
❑ Fascia
LOCATION OF WTNDOWS
NUMBER
ATE�ZIP
A
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDMG DECKS,
ADD1TlONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WlNDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(LTSING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATTON $(o ri A� _�i� 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
$ `7jJ' !�S
$
$
$
$
$
$
$
$
$
$ �
See Back Page for Fee Schedu(e
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 aavable to: Citv of Fridlev Attach ;
lations
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL1D UNTIL PROCESSED
I hereby apply for a bulilding 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 pian in the case of tl work whic r�q 'r review and approval of plans. � �' 1� j 1`
SIGNATURE OF APPLICANT PRINT NAME ` . DATE T���I T_
APPROVAL INSPECTOR SIGNA�URE