P - 47777Building
Inspections
763-572-3b44
763-502-4977 FAX
DATE � I � � � � �
SITE ADDRESS ___� � _�
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
1NSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011 i'jr-�--� Ce ic\
— YOUR E-MAIL ADDRESS �
► C IP_(1 rV ►P� , � S-t�'
❑ OWNER �CON'1RACTOR
NAME: � h� r'P SOL P �
.�nn�ss: S lo?O L.[ r � �`�5-�-�.
PHONE: �.Q I, ,7�'�3(�., Iip�
NAME: � 1 L-,1�� /� _� _ �- i _ _. 1,.
Permit No����
Received By: �
Date Rec'd: �
�' � ct ( e STA ZrP
STATE LICENSE # `p� Q1 V LEAD CERT NUMBE;
ADD�SS:��{ � a � �, �.,�.a�,� ___ �I � c� r�! * �4�
PHONE �. )_ y a�, — y� �� FAX iDs� —
�SINGLE FAMILY(NEW CONSTRUCTION
TWO FAMIL�/NEW CONSTRUCTION
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
�AINTENANCE/REPAIR
DESCRIBE WORK BEING DONE:
SIZE OF TMPR(IVFMFNT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ GARAGE/SHED
❑ ROOF
❑ SIDING
❑ SWIMMiNl: P(N
SIZE
STORIES
❑ ADDITION
❑ REMODELING
.✓ cind �x�
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHF,D GARAGE
❑ DETACHED GEIRAGE
�-T io�S��-
❑ WINDOWS
❑ DRAIN TILE
�QTHER �. f R D
F
���
�
_STATF.�JZIPS_�g
�)
wal�
(G� � �v�
SO FT
BASEMENT REMODELING SUBMIT�
1. E�sting Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
OSoffit ADDTTIONS & PORCHES SUBMIT:
❑ Trim 1. Site PIan/Survey showing the existing structures
❑ Fascia and proposed project.
WINDOWS 2- Two sets of constnxction plans
IN EXISTING OPENINGS ❑Yes ❑No 3. Energy Calculations
LOCATION OF WINDOWS FOR WINDOWS – PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES & MANUFACTURE STICKBR ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING T �1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 1 Q�O� OCCUPANCY Tvnr,
Pernut Fee � �—
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ ^ :,
$ l
$ _:5, ��'
$ �i���
$
$
$
$
$ _
See Back Page for Fee Schedule
65% of Building Pemut Fee
.001 times the total job valuation
.0005 x Pernut Valuation Minimum $S.t�
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Deternuned 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 I acknowledge that the information above is complete arui accurate; that the wark will be in
cor►forn►ai�ce with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
pernut but only an application for a pernut and work is not to start without a permit on site; that the work will be in accardance with the
approved plan in the case of a 1 work which requires review and approval of plans.
SIGNATURE OF APPLICAN _PRINT NAME
APPROVAL INSPECTOR SI A RE r� ���` ��Sr�.N M- }!� b'�—DATE �� i d � 11