P - 36040Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�_
SITE ADDRESS �
THIS APPLICANT IS;
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
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� OWNER
S C.F �i �2--
ADDRESS: �}O �--% f C���iKOnf'" CI �►v F CITY
PHONE: � 6 3-'�^j 6' 7<-10 �
Permit No.: !�(/ " 'J�
Received By:
Date Rec'd: 0
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STATE��ZIP SS�i�i,�
NAME: e �1 � �s�UY'anpri
STATE LICENSE # �% d� LEAD CERT NUMBER �' J %� I
ADDRESS;�'a ,3 (� C� S vn � s��l� C� CITY ���y STATE�i� ZIP 30
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❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION � GARAG
O BASEMENT FINISH � ROOF
O DECK ❑ SIDING
❑ SWIMM
�L!��Till:7'7
SIZE
c�rnn rno. . .
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: ' �� � �✓'R
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
I PROPOSED HEIGHT:
' SIDING
; ❑ Vinyl
❑ Aluminum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
OSo�t
❑ Trim
� Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
INSTALLED
NUMBER OF WINDOWS
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDING DECKS,
ADD1T10NS. & PORCHE& SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of conswction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE ST(CKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
SING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�,OO� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
$ �''� .� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ , .001 times the total job valuation
$ ?,+ ov .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 qavable 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 th� Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and work is ot to start without a permit on site; that the work will be in accordance with the
approved plan in the case of orj� r e and approval of pla s. �--. /�
SIGNATURE OF APPLICANT � PRiNT NAME �P��L `(i'JTI'C— DATE `-'/Q �I I
APPROVAL INSPECTOR SIGNATURE
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