P - 48558Building /,
Inspections � 1-�
763-572-3604 �
763-502-4977 FAX
DATE
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER ❑CONTRACTOR
Sz,:v
NAME: �Hoj✓rv�>
Permit No.;.F c
Received By:
Date Rec'd:
ATL`�'`" ZIP
STATE LICENSE # �-�-�' � � / � -J LEAD CERT NUMBER
ADDRESS: I ;. CITY `^ ti; Ji+ STATF�/�/,�IP ``�S Z�
PHONE h 2 Z� � FAX 7(c; '�-j�1' S � �-'��
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FIN[SH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: � �`d'" �-�"'� �
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
' WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
' TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACNED GARAGE
❑ DETACHED GARAGE
❑Softit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDO
❑ WINDOWS
❑ RAIN TILE
�THER
/ �
��:�i �
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDING DECKS,
ADDITIONS, & PORCHES SUBMIT:
l. 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)
TOTAL JOB VALUATION $ �� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
i Total Due
$ ���`��'
$
$ ^� "�
$
$ .�,, _ �- ,.
$
$
$
$
� ,_ . �'i �
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 Detennined by Engineering
Agreeinent necessary ( ) Non Necessary ( )
Make checks navable to: Citv of Fridlev Attach
ulations
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 o wh�" requires review and approval of pl�,ns.F - + �I
SIGNATURE OF APPLICANT �/'� ,-�"'_ PRINT NAME r I L� : U �`> DATE C� \��" 1�7 �C, ;
APPROVAL INSPECTOR SIGNATURE '� J`- � A� —� �
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