P - 47292Building
Inspections
763-572-3604
763-502-4977 FAX
v�.�
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PEBMI'1' TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
_ EFFECITVE I1-2011
E-MAIL ADDRESS
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� �WNF;R �ONTRACTOR
CITY
I�E�r�^.i
STATE LICENSE #_�j (1� Q(a � j�_ 4,EAD CERT NUMBEF
.a�D�ss:��-�.'
PH01VE `% /��� �� � � CITY�
�i — �.S'' ' � � � o�. Fr�X `7 L _�.._
�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH �tOOF
❑ DECK ❑ SIDING
SIZE
STORIES
- --__.� _ �...,
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
-�MAINT'ENANCE/I2EPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: I�H-�- O F�--�Pfi1j"L.T .vtfj'��� n<
SIZE OF IMPROVEMENT LENGTH WID�
ROOFING �HOUSE ONLY
NUMBER OF SQUt1RES � ❑ HOUSE Bc GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Okher
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ DRAIN TILE
❑ OTF3ER
L
Permit No.:
Dac�;�� �.' I r—� �t'
, � _ ��
_STATE�
_ ai
��STA
_ ��CJ G-
BASFMENT REMODELING SUBMIT•
1. Ettisting F1oor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit SIDING/SOFFIT/FASCIA �DITIONS .e. pOR S �i1RMIT�
O Trim REMOVED? ❑ YES ❑ NO I. Site Plan/Survey showing the existing shuctures
❑ Fascia and pmposed project
WINDOWS 2. Two sets of construction plans
IN EXISTING OPENINGS �Yes ❑No LOCATION OF WINIDOWS � 3 3 ao, �i 3� ��SY Calculations
OR FOR NEW OPENiNGS-DESCRIBE SIZB OF � FOR WINDOWS - PROVIDE U-VALUE AND
OPINING CIIANGES & a(Jpk MAN[JFACTTJRE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED I{�il,` N[JIvIgER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDiTLE)
'OTAL JOB VALUATION $ ,.� �, (�C (J. U� nnnrm � wr�,<, ..._A_
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$ �2 °- See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ � 3� .001 times the total job valuation
$ Z�? ) .0005 x Permit Valuation Minimum $5.00
$ �t� $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 ( )
� l.3 £f �.3 Make checks payable to: Citv of Fridie� e ff4..
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID iJNTIL 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 pernut and work is n t to start without a permit on site; that the work will be in accorda.nce vvith the
approved plan in the case of al rk w ic uires revi and appr al of plans. / ��
SIGNAT`URE OF APPLICANT p NAME_ M r�/l ��--rJD�l S DATE �%' /� /% �
APPROVAL INSPECTOR SIG?VATIJRE . - -�