P - 45211Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � 1 ��� �
SITE ADDRESS �"Z
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMTT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR E-MAiL ADDRESS
vT`1 �i � �L. I•c�,.� � �
❑ OWNER �ONTRACTOR
NAME: �Gt�►�, t"►raY�..v�.
ADDRESS: � 5.S t� C� rr') �1�1": I�r C CITY
PHONE:
NAME:�L!�� i'w�=5 t� i1 ��L�
STATE LICENSE # Z�S °� �� �
ADDRESS: Z,(� 1� ��'it v�C,u�% :3�'• y
PHONE (, 1'�.. �" �.�..�'�.c7 " 1 U 15
Q SINGLE FAMILY/NEW CONSTRUCTiON
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMETVT FINISH �(„ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POI
Permit No.:�� I °-C1' � I �i`
Received By: �
Date Rec'd - l
STATF���Y}. ZIP
/)'h � �-- L'
EAD CERT NLIMBER
CITY � Gt°' STAT�� ZIP ,5�.� �i/
F,ax � -� "3 — �i � 3 - ,� � �'�
SIZE
STORIES
❑ WINDOWS
[7 DRATN T1LE
O OTHER
TY.PE OF WORK: ❑ NEW HOME CONSTRUCTION D ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING
SIZE OF 1MPROVEMENT
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HETGHT:
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_
❑ HOUSE OTJLY
[J HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
Q Fascia
LOCATION OF WINDOWS
NUMBER
HEIGHT
FT
BASEMENT REMODELtNG SUBMIT:
t. Existing Fioor P(an
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION (NCI.UDiNG 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:
(US j,T,HE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ �1(J 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
$ �j�, ..15 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �, i v .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ � f�Q $5.00 (State Licensed Residentiai Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ #}+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ Make checks payable to: City of Fridiev Attach
lations
THIS IS AIJ APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 acknowledge t2►at 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 wo c is np�to start without a permit on site; that the work wilt be in accordance with the
approved plan in the case of all work w' e're�,r ui �and approval of pl�s_- � / �/ %
SIGNATURE OF APPLICANT ,, �JC�NAME /��/�t. /`1/ I //."��k DATE � ��� ! �
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