P - 40829Building
Inspections
763-572-3604
763-502-4977 FAX
DATE J "v` '
SITE ADDRESS _
THIS APPLICANT IS
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MA1L ADDRESS
❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: �v,��Q ���-t,(-
TENANT ,qDDRESS: ,S 1�}✓-i t-� CITY
PHONE. �-(o �- ��a' 1 T�
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
Permit No.�� �''� ����
Received By�'�' J �+
Date Re��'.'� � � � � � �
STATE ZIP
NAME: �_� �j�.,�� � j L L L
STATE LICENSE # .3 � LEAD CERT NUMBER
ADDRESS:�����J� �/ s��� CITY ' vf� STATE ihl�i ZIP���
PHONE �!} •,]`y`( -' .�-6(.j S FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES '
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FiNiSH �` ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑� EW HOME CONSTRUCTION ❑ ADDITION
�,MAINTENANCE/REPAIR ❑ REMODELR�IG
DESCRIBE WORK BEING DONE: ��G►' �� 'F-- j� (`G�,,�
-�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
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 ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
� Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of struc!ural members to be used
FOR NEW CONSTRUCTION iNCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. 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 $ � f GC�O 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�I��
�s
� ,
�� ��
$
$
$
$
$ , �
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 payable to: City of Fridley
Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
1 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 Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and wor1 ' start without a permit on site; that the work will be in accordance with the
approved plan in the case of ork wh' r ' w a approval of �1.�1s. ' `' /� ^�
SIGNATURE OF APPLIC T PRINT NAME J•tM,t.S l.�-�� DATE 7'd� ��
APPROVAL INSPECTO SI ATURE