P - 46718Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�[�
SITE ADDRESS �
THIS APPLICANT [S:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
, PROPERTY TYPE
BUILDING
RESIDENTIAL APPLICATION
❑ OWNER
ADDRESS:
STATE LICENSE #
Permit No.: �6
Received By:
CITY OF FRIDLEY vate ��: ,�
EFFECTIVE I-1-2011
YOUR E-MAI ;ADDRESS No� w69C�tc���PU C�A��,� IM�I • f ���
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�ONTRACTOR
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, S �cE[.C�� �Y CITY ��\d��� STATE��'�ZIP � � L,��
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PHONE — `' �I..I (o`'� `� 'C'
INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
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LEAD CERT NUMBER���,
� CITY /y�n,c.J'C'�`eh
F,� ~�6� ��1�� s
SIZE
STORIES
P.ERMIT TYPE � �DITION ❑ GARAGE/SHED ❑ WINDOWS
O BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING � OTHER
❑ SWIMMMG POOC,
YPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
; DESCRIBE WORK BEING
i SIZE OF [MPROVEMENT
ROOFING
I NUMBER OF SQUAR����
' GARAGES
i PROPOSED SIZE:
' PROPOSED HE[GHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
t.
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
M EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENtNGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WMDOW TO BE INSTALLED NUMBER OF �
HEIGHT
ATE I� kZIP �� � 3 C7
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.
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUEAND
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)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ 1t1•"L�
$
$ �1
$ `Z
$ l
$
$
$
$
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 Fridle_y Attach
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 al or1 ich requires review and approval of ply� ns�. I ..� j
SIGNATURE OF APPLICANT ��:2 :�� PR1NT NAME C..�"� \n°� �C<� 'J`�—� DATE lF� ( ��/�L� t I
APPROVAL INSPECTOR SIGNATU