P - 39984Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � L
SITE ADDRBSS �
TH[S APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SL3BMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT_
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
VE I-I-2011
E-MAIL ADDRESS
❑ OWNER �CONTRACTOR
ii'flJf��IL'l��lf'L���
� � � • o . �i I I�..� t'
C[TY
N.aNrE: � - �� �r1"�(�X � r'�l�dEf-� Yl� U'`'zss� �l1`' `"�
STATE LICENSE # ' i� Z- • L AD CERT NUMBER.
ADDRESS: � v �S^I S,� � �Z� � C � �' � CITY G�
PHONE �� 3' Y'�i �" �� v` D FAX !
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT F[NISH 6 ROOF ❑ DRAIN TILE
� DECK ❑ SIDiNG ❑ OTHER
❑ SWiMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
.�MAINTENANCE/REPAIR ❑ REMODELING
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes �130
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENII�iG CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WtNDOWS
NUMBER OF
WIDTH _ _ __ HEIGHT
, �- � �-t;� � I `��
Permit No.: �'_
Received By: � �`;�
Date Rec'd: � � � " ( �
� �"vL�. � l�'�%
_STATEI%�ZIP
� O ��_/
ATE��ZIP��
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.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
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)
COTAL JOB VALUATION $ (�(N9� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
5urcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
���
�
�
�
•
iiia.�1
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 pavable to: Citv of Fridley
Attact►
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
1 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 all rk which requires review and approval of plans. / - / /
SIGNATURE OF APPLTCANT ��'��� �'y�/!y�_ PRiNT NAME T7'8`'7 �°�? � IJ�C�A' DATE � ���[ I
APPROVAL INSPECTOR SIGNATU