P - 35411Building
Inspections
763-572-3604
763-502-4977 FAX
DATE l '"alb°'
SITE ADDRESS �o
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
EFFECTIVE ]-1-2011
YOUR E-MAIL ADDRESS
C`°C'i �wl �l�L'. �
❑ OWNER i�ONTRACTOR
NAME: � +L�l � � � e > C G
ADDRESS: � � I'CY �
PHONE:_ � S�r - C( � � ' �O
NAME: �; pd'S J a�1 C
STATE LICENSE # � O(� 3�' �`3 LEAD CERT NL1M$EF
ADDRESS: �� '~—� CITY
PHONE 3 '" � � FAX
INGLE FAMILY/NEW CONSTRUCTION S[ZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ BASEMENT FiNISH
❑ DECK
TY.PE OF WORK: ❑ NEW HOME CONSTRUCTION
�vIAINTEN ANCE/REPAIR
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT �
ROOFING
NUMBER OF SQUARES �_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
� Vinyl
❑ Aluminum
❑ Other
ea
C] GARAGE/SHED ❑ WINDOWS
�'•ROOF ❑ DRAfN TILE
❑ SIDTNG ❑ OTHER
❑ SW[MMING POOL
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
�HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
WiDTH
Permit No.: - -'cG —i�f 3d �
Received By:
Date Rec'd:
ATE�tI� ZIP
�
STATE�/�ZIP,
BASEMENT REMODELINC.i SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of strucwral members to be used
FOR NEW CONSTRUCTION MCLUDING 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.
TYPE OF WINDOW TO BE INSTALLED_ NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USIN� THE 1997 U:B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ ��QOO --�� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$ �
$ .
$
$
$
$
$
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= fix$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley Attach
lations
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 idley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit an k is t to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all w rk h' h require approval of plans. / ..f�
SIGNATURE OF APPLICANT P�INT�IAME �i�t�A e 1 S�''��� �"` DATE ��G' I�
APPROVAL INSPECTOR S[GNATURE /t /\