P - 46811Building
Inspections
763-572-3604
763-502-4977 FAX
DATE i �r����N
SITE ADDRESS r�c 1
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LIEENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
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Pertnit No.:� � �� �� �
Received By:l � 1��f"
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YOUR E-MAIL ADDRESS � t �
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❑ OWNER
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STATE��!/VZIP J�
NAME: L� S m f ��'"k�-<-��"��-)
STATE LICENSE # bv10 ;�j �_ �'�{, Z- LEAD CERT NUMBER ��
ADDRESS: I� ��%�S�G�i +�-o' CITY STATt�I►!_�IP_!���
vun�.� %/�%,� ��%�. � % � �.. . F� -
GLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STOF
❑ ADDITION
p BASEMENT FINISH
❑ DECK
0
❑ SIDING
❑ SWIMMING POOL _
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ ENANCE/REPAIR_ ❑ REMODELING
DESCRIBE WORK BEING DONE: �
SIZE OF IMPROVEMENT L TH WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES � �'�OUSE & GARAGE
GARAGES
PROPOSED SIZE:_
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
i. Existing Floor Plan
2. Proposed floor plan
3. List of sttuctural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT:
�Soffit SIDING/SOFFIT/FASCIA 1. Site PlanlSurvey showing the existing structures
❑ Trim REMOVED? ❑ YES ❑ NO and proposed project.
❑ Fascia 2. Two sets of construction pl�s
3. Energy Calculations
WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
IN EXISTING OPENINGS ❑Yes QNo LOCATION OF WINDOWS MANUgACTURE STICKER ON WINDOW-
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED N[JMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TnTAL TOB VALUATION $ OCCUPANCY TYP'E
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ '�.,,;. See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ � .001 times the total job valuation
$ U .0005 x Permit Valuation Minimum $5.00
$ � Q , $5.00 (State Licensed Residential Contractors)
g $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 ( )
� 1 Make checks payable to: City of Fridley Atta�
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge 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 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 ork which requires review and approval of plan,s���� �� � DATE i, '�% '�/
SIGNATURE OF APPLICANT PRINT NAME L
APPROVAL INSPECTOR SIGNA
PLEASE NOTE: SEPARATE PERNIlTS AR� �QUIRED FOR PLUIviBING, ELECTRICAL AND MECHANICAL WORK