P - 44886Building
Inspections
763-572-3604
763-502-4977 FAX
DATE V ` � "'
SITE ADDRESS �lJlj�
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
N
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER �}CONTRACTOR
t.�
Permit No.:�b � �� ���
Received By:
Date��l:��f! ���� 1
ADDRESS: �4SS �� �'j'f � J CITY [�r+d%t,/ STATE �'I� ZIP
PHONE: 7C�3 ^ S�� � 27 S
�
Tr.�.
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: ��J3� llb� �`--� � CITY���/N STATE�VZIP �'3I b
PHONE �OI Z� R 9g -0�131 FAX
C!l'SINGLE FAMILY/NEW CONSTRUCTION SIZE
� TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED INDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
CI SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑� DDITION
❑ MAINTENANCE/REPAIR Q"REMODEUNG
DESCRIBE WORK B G DONE: �►'+GZ
SIZE OF (MPROVEM� �Z�1�-I
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED S[ZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS � /
IN EXISTING OPENINGS L�t'%es ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES & t
TYPE OF WINDOW TO BE INSTALLED �ol4s'
❑ HOUSE ONLY
❑ HOUSE & GARAGE
O ATTACHED GARAGE
� DETACHED GARAGE
osoe�c
❑ Trim
❑ Fascia
LOCATION OF WINDOWS ��-5�M[!'��
Vt n� S�NUMBER OF
,�
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposcd floor plan
3. List of structural members to be used
S•
FOR NEW CONSTRUCTION MCLUDING 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:
(U�NG THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �IS()"� 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
$
$
$ � �
$ �
$
$
$
$
$
See Back Page for Fee Schedute
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 pavable to: Citv of Fridlev 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 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 all ork whic equires review and approval of pl s. ,n� f
SIGNATURE OF APPLICANT PRTNT NAME � n n i t / ��. ��� DATE I�" 2 l� I I
APPROVAL INSPECTOR SIGNA URE