P - 41188Building
Inspections
763-572-3604
763-502-4977 FAX
�i DATE "1.T ZD
SITE ADDRESS _
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
Permit No.:
Received By:—� ��—
CITY OF FRIDLEY Dat��a��: � „ �,��1
EFFECTNE 1-I-20] 1
YOUR E-MAIL ADDi2ESS � t��l. C> y� y\n��, `, \�(.b vtin.
�.1 �-
f�OWNER ❑CONTRACTOR
PROPERTYOWNER/ NpME:�v\��,�,F �,.� ��oi�S
TENANT qpDRESS: � c� K1� C� ��z�)�S''CL L" t_. 1`�i� C(TY �(Ll,(L.,�,�, STAT�✓I�LZIP _�`�-j3Z-.
.�
PHONE: ''�(,3. �3'L. 1 S'S`�
CONTR.ACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
STATE LICENSE #
ADDRESS:
PHONE
� SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ �D17'IOtv
O BASEMENT FINISH
O DECK
❑ GARAGE/SHED
�#ROOF
❑ SIDING
❑ SWIMMiNG POOL
LEAD CERT NUMBER
CTTY
FAX
SIZE
STORIES
❑ WINDOWS
❑ DRAfN TILE
❑ OTHER
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITION
IBMAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE: (�-C�C� o�� �(��a'�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT
ROOFING
NUMBER OF SQUARES %�'
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
O Other
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPF. nF WINnnW Tn RF. TNSTAI.f .F.n
❑ HOUSE ONLY
,�HOUSE & GARAGE
❑ ATTACHED GARAGE
� DETACHED GARAGE
❑Soffit
❑ Trim
� Fascia
LOCATION OF WINDOWS
NIJMRFR nF
STATE ZIP
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADDITIONS & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction pians
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 2997 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
Total Due
$ /dS,d�"
$
$
�--
$
$
$
$
$
$
$ � �.
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 Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks aavable to: Citv of Fridlev
Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCESSED
I hereby apply for a building permit and I acknowledge that the informaiion 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 d 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 rk w ic re "r view and approval of plans.
SIGNATURE OF APPLICANT PRINT NAMET%�Ii, )��_�CiLd �"S DATE ��/Z27 l(
APPROVAL INSPECTOR SIGNATURE