P - 37243Building
Inspections
763-572-3b04
763-502-4977 FAX
DATE — r
SITE ADDRESS I
THIS APPLICANT IS:
PROPERTY OWNEW
TENANT
� CONTRACTOR
� SUBMIT A COPY OF
� XOUR STATE LICENSE
! AND CERTIFICATE OF
� INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
ItOOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
� l(
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLE�
EFFECTIVE 1-1-2011
Permit No.:
Received By:
�. �� � . , , �
� �
YOUR -MA1L ADDRESS lG� // s Q l� C�<i?
/Iv �vz5/�'�� I� � cC r
- �C 2 /� �
� OWNER .P1�ONTRACTOR
,. �� /�s� f �,'i %��
ADDRESS: �S � ��-rc��'��+-'�CITY V �/'"', �%N� STATE��-ZIP�_
P3-iONE:
Ns�tvtE: G G�/ S CC��z �i -c� �•r
STATE LICENSE # [��� �� LEAD CERT N1IMBEK
ADDRESS: C G�{ �Y ��i�' �"� S�' �C� ) CITY - r� 16t. l� STATE�!72ZIP`� S�C�t
PHONFi (�/�- �dZ-�U _ (o % `� � FAX �
H'SINGLE FAMILYlNEW CONSTRUCTION
❑ TWO FAMILYINEW CONSTRUCTION
❑ ADDITION ❑ GARAGEiSHED
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SiDTNG
❑ SWIMMING POOL
31ZE
STORIES
INDOWS
❑ DRAIN TILE
❑ OTHER
❑ NEW HOME CONSTRUCTION ❑ ADDITI�N
[�oi�TENANCE/REPAfR ❑ REMODELING
C �%z C-e �_ (Z � 2 o��Y,.S �L
LENGTH WIDTH
❑ HOUSE OIVLY
❑ HOUSE & GARAGE
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WiNDOW TO BE INSTALLED
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑So�t
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
�:
BASEMENT REMODELiNG SUBMIT:
1. Existing Floor Plan
2. Proposed floor pfan
3. List of struc+.ural members to be used
FOR NEW CONSTRUCT[ON INCLUDING DECKS,
ADDITIONS, & PORCHES SiJBIvSIT:
l, Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS - PRQVIDE U-VALUE AND
MANUFACTURE STICKER ON WtNDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING TNE COST OF LABOR AND MATERIALS:
(USIN HE 19� U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION � ���(� �� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Totat Due
$ ��Jjt�i.'l �
$
$ ��G
$ l
$ �T�
$
$
$
$
$
$ �- . c
See Back Page for Pee Schedule
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 payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALfD [JNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is comp(ete 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 which quires review and approval of pians. /
SIGNATURE OF APPLICANT a���✓"t� ��_�'r/` -� PRINT NAME ��2���C�/ � DATE �•^ �1� '��
APPROVAL [NSPECTOR SIGNA R�