P - 40237Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � `
SITE ADDRESS �
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
' r� d �%t ''C
❑ OWNER
PROPERTY OWNER/ N�tE:
TENANT
ADDRESS:
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT_
CITY OF FRIDLEY
EFFECTIVE I-I-2011
YOUR E-MAIL ADDRESS
C�lii7
� �- i,,.,.�;�r.-�
Permit No.: -� l � J�
Received By:
Date Rec'd: �
ATE ZIP,
STATE LICENSE #_�G �0 3� S L�D LEAD CERT NUMBER
ADDRESS: ��S �� ��/+4nc4- �� CiTY C��..� t� �.,� STATE/'�rf ZIP � s 3 uy
PHONE _ 7("p3'`i�13� (�p�i�-� FAX
'B-SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED � WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED STZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
LENGTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
WINDOWS
FT
BASEMENT REMODELING SUBMIT:
1. Existing Fioor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS_ & PORCHES SLJBMIT:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR W[NDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USIN�-THE 1997 jJ �C FEE SCHEDULE)
TOTAL JOB VALUATION $ 9a o b ��F �( 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
$ `�'7. 2 5
$
$
$ I
`V V 4
$
$
$
$
$
$ . O�
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 Attach
THIS IS AN APPL[CATION 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 d codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application 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 w c q' s review and approval of pla ���� ,� p •
SIGNATURE OF APPLICANT PRINT NAME v�(vY f;��'—�� DATE /��" t j
APPROVAL INSPECTOR NATURE �
2.-7 ��_