P - 36882Buiading
Inspections
763-572-3604
763-502-4977 FAX
DATE / U '^ oC �=
SITE ADDRESS _��t�
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:
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SI2E:
PROPOSED HEIGHT:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2010
YOUR E-MAIL ADDRESS
S�'. /U � C,
❑ OWNER
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Permit No.: ��J
Received By: ' • `'' _
����' � 2 8 010
NAME: ('�{�2L l� N E G��f2/�E,�1 /V
ADDRESS: Iv�n K(D �2CfJL�1� SY CITY ���D • STATEL
PHONE:
NAME: .1�� �L�L S L/5%/-%�G .Y
STATE LICENSE #�_ -�.Za,j f� D 3�� EXP DATE �� '� � �
ADDRESS:' �� �`'.�a LL'Q V/CI. L� � CITY D STA
PHONE 16/� R7'�— %O II FAX %G 3 J�Z %- oD2
❑ SINGLE FAMILY/NEW CONSTRUCI'ION
❑ TWO FAMTLY/NEW CONSTRUCTION
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
h i�.�
SIZE
❑ NEW HOME CONSTRUCI'ION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
«. R� Od
LENGTH � WIDTH
❑ HOUSE ONLY
C] HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
O DRAIN TILE
❑ OTHER
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
�
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1• Site PIaNSurvey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Caiculations
IN EXISTING OPENINGS ❑Yes �No 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:
. L'_ (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
$
$
ODm. °a
'ANCY
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $.50
$5.00 (State Licensed Residential Contractors)
$2100 per SAC Unit (Plans to ]VIWCC for determination)
$+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement riecessary ( ) Non Necessary ( )
Make checks pavable to: City of Fridley Attac
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 comptete 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 o wo which requires • v'ew d approval of plans.
SIGNATURE OF APPLICANA�%�� a PRINT NAME //� //C�� f'L�/SL��� O oZ S�
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