P - 41256Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �' �jLi' j(
SITE ADDRESS �� 7�
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
, YOUR STATE LICENSE
I AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
BUILDING
RESIDENTIAL APPLICATI4N
CITY OF FRIDLEY
EFFECT4VE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER
NAM�: F�C�� d`t'�.a.i-T�.:-t'
ADDRESS: L�� ?(.� C�iar+'k.,-1 �°'� CITY
PHONE: (L'� Z- Cv 7O' � cS�! Z
Permit No.:
Received B
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ATE ZTP
t�AMt: l.v`a-f�YVt2�'1 C EkS �.r.✓�iv,., �lil� •
STATE LICENSE #���✓ S�%� j�+ LEAD CERT NUMBER
ADDRESS: ��Si'l3 (�✓�.1�-}- �.F— CiTY �:rt ��Ic.` STATEm/l/ZIP cSS��'Y
PHONE %(U,3 ' �%�',3 � ('(� 7 Y FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORTES
PERMIT TYPE ��DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
O SWIMMING POOL
TYPE OF WORK: �❑ NEW HOMB CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT_
ROOFING r�
NUMBER OF SQUARES o`3
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 W[NDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of struc!ural members to be used
FOR NEW CONSTRUCTION INCLUDING 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 $ 6 6& 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
$ , Z..
�
$
$ � �
$ :S c��
_$
$
$
$
$ � 1 � ! }vl
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 Residentiai 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 UNTIL PROCESSED
I hereby apply for a building permit and 1 acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances an codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application fo a p it an 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 ' h uires review and approval of plan ,.
SIGNATURE OF APPLICANT PRINT NAME ��L+-r... ��,/�✓C DATE �-3a - l/
APPROVAL INSPECTOR SIG TURE