P - 35822Building
Inspections
763-572-3604
763-502-4977 FAX
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SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
Permit No.:
Recei
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I EFFECTIVE 1-1-2011 �
YOUR E-MAIL ADDRESS Sr✓Fo C> �rQ ��7 E.'�C7`tP /'/ 4/' S. CO �u
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OWNER ONTRACTOR
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ADDRESS: lP K�"� ✓G -/�vCCITY �S/'• i¢L! L STATE 1YI�ZIP '�.5 S'�%�2
PHONE: "%C�.3 ° %�%.2~ � �, j
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STATE LICENSE #
/NEW CONSTRUCTION
BASEMENT FINISH
DECK
SWIMI�4ING POOL
TYPE OF WORK: NEW HOME CONSTRUCTION ADDITION
MAIIV'I'ENANCE/REPAIIt REMODELING
DESCRIBE WORK BEINCi DONE: pA�
SIZE OF IMPROVEMENT LENGTH Wip'1'g
ROOFING HOUSE ONLY
NUMBER OF SQUARES � HOUSE 8c GARAGE
GARAGES ATTACHED GARAGE
PROPOSED SIZE: DETACHED GARAGE
PROPOSED HEIGHT:
CERT
DRAIN TII.E
OTHER
f T —'/`f'yS5 �.�
i , TATE i%�IP���
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BASEMENT RFMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of struchua( members W be used
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
Vinyi ��t ADDITIONS. 8c PORCHEg crrwr,riT:
Aluminwn T� 1. Site Plan/Survey showing U�e existing stcuctures
Other Fascia � ProP�� Project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS Yes No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES 8c
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE�}997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION S �i �Q�� �v OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb C�xt Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
� �%-' d 5 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .� .0005 x Pernrit Valuation Minimum $5.00
$ $5.00 (State Licens� 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
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII, PROCESSED
I hereby apply for a building permit and I aclmowledge 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 understsnd tlus is not a
permit but oniy 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 ��p�res�v' d approval of plans�'� � ���/' o /
SIGNATURE OF APPLICANT PRINT NAME �N ` �! /�'1tt�=i���'L'°�DATE_ /J ' � ( �
APPROVAL INSPECTOR SIGNA