P - 41217Building
Inspections
763-572-3604
763-502-4977 FAX
SITE ADDRESS ,p�!
THIS APPLICANT IS
PROPERTY OWNERI
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
�ND CERTIFICATE (JF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
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Permit No.: � ��
Received By:
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YOUR E-MAIL ADDRESS �`���/�,�yij���•nrL�Gy rD�(�,p�1 �,s 9yJI� CCjey,i
� ❑ OWNER �CONTRACTOR
NAME:� � ��f/ �
ADDRESS:,�2E::i� �'' , "+ '
PHONE: '%La�'°- SY %I — /��
STATE LICENSE #
PHONE
ciTY �� ( /C�;u sTaT�'J�z�r S# .3 �il
o�iJ6%t3ti� � LEAA CERT NUMBER I¢r ��% —
��J�C cS�/°'G'f?7� CITY�� ,�+STAT��ZIP.SS%D
�C��C���.s'°_ FAX /`,,s%~�Ia.sw` %%�i.i�-
SINGLE FAMU.Y/NEW CONSTRUCTION
TWO FAMILY/NEW COPISTRUCTION
u allll111UN ❑ GARAGE/SHED
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
O S WIMMING PO(
SIZE
S1'JP`iES
❑ WINDOWS
❑ DRAIN TILE
� OTHER
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
'MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �/4 �`�
SIZE OF IMPROVEMENT LENGTH VVIDTH
ROOFING ❑ HOUSE ONLY
PdiJMBER OF SQUARES C] HOUSE & GARAGE
GARAGES
FROPOSED SIZE:
PROPOSED HEIGHT:
SI�ING
❑ Vinyl
❑ Aluminum
� Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
�Soffit
❑ Trim
�C'Fascia
WINDOWS
LV EXISTING OPENINGS �Yes �No LOCATION OF WINDOWS
C�R FOR NEW OPENINGS-DESCRIBE SIZE OF
QPENING CHANGES &
HEIGHT
BASEMENT REMODELING SUBMIT`
l. Existing Floor Plan
2. Proposed flooe plan
3. List of structu�al members to be use�i
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS & PORCI-LFS SUBMIT�
I. Site PIanJSurvey showing the existing structures
and proposed project.
2. Two sets of canstruction plans
3. Energy Caiculations
FOR WINDOWS — PROVIDE II-VALLQE AND
MANUFAC'ttJRE STICKER ON WIN��OW,
� TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�� USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ y�p %p�j� __ OCCUPANCY TYPF
F'ennit Fee
F'lan Review
Fise Surcharge
Surcharge
L.icense Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �(� �; 2.`.� 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 ( )
$ ) o��� Make checks pa�able 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 and accurate; that the w�ork v✓ill be in
c��nformance with the ordinances d codes o he 'ty o Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatio pe d w r s n t to start without a permit on site; that the work will be in accordance r�vith the
a�proved plan in the case of o w c � s v and approval of pla �,/' �`/
S=GNATURE OF APPLICANT P�IN�VAME / ffj(t,L'�,►t,�t,h DATE '
A�PROVAL INSPECTOR SI ��ir� �