P - 47262Building
Inspections
763-572-3604
763-502-4977 FAX
DATE '!�. �l ��l� �/
SITE ADDRESS 6 �C
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A CQPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPRnVF.MFNT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 11-20ll
,�("�WNER
NAME: (j
ADDRESS:_�
PHONE:��
�-r
NAME:_�
STATE LICENSE
ADDRESS�
YOUR E-MAIL ADDRESS _�
.�;>' �7 �
❑CONTRACTOR
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' U � � L• CITY
` xi _ � i , i, �
�viv� � l� S '— / (� �-k— "/ �-/H �
SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILYMEW CONSTRUCTION
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
0 MAINTENANCE/REPAIR
❑ GARAGE/SI
❑ ROOF
❑ SIDING
❑ SWIMMING
Permit Noa.l�j ` �
Received By: �
Date Rec'd: '� � e
a � jYI S �u.
STA1'L��ZIP ��'S�3 �..
LEAD CERT NUMBER EXP:
�CITY � STAT�ZIP�_Z
FAX '
SIZE
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ DRAIN TILE
❑ OTHER
HEIGHT
FT
BASEMENT REMODELING SUBMIT
1. Existing Floor P1an
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS & PORCHES SUBMI7'
O Trim REMOVED? ❑ YES ❑ NO � Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1 97 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $_�'C7 _�� 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
� �s7�'s"=�,�-4�'Back Page for Fee Schedule
$ .-�- 65% of Building Permit Fee
$ _: .S .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 ( )
$ ei , Q Make checks payable 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 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 p it and work is not to start without a permit on site; that the work wili be in accordance with the
approved plan in the cas all ork ch ires review and approval of plans. f J} / /
SIGNATURE OF APPLICAN - PRINT NAME �/1 !� � cz i�(i([� DATE �� / d/��/
APPROVAL INSPECTOR SIGNATCJ