P - 35233Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_�
SITE ADDRESS �
THIS APPLICANT IS
BUILDING Pernlit rto:� �� i1 ` t�-� -�, �-
RESIDENTIAL APPLICATION Received By: n�
CITY OF FRIDLEY Date Rec'd: --
EFFECTIVE 1-1-201I
YOUR E-MAIL ADDRESS
❑ OV✓N�ER �CONTRACTOR
PROPERTY OWNER/ NAME:�,
TENANT
ADDRESS:
PHONE: %� .� -
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BETNG
SIZE OF IMPROVEMENT_
N.aME:r ��Zc �.n r� ✓ f ri
STATE LICENSE # ; �U�' �'�%S
CITY
D CERT NUMBE
CITY� �
PHONE ��.' S�/.j `7 "5.� 'S FAX
@'�INGLE FAMtLY/NEW CONSTRUCT]ON SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH /B'itOOF � DRARJ TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMfNG POOL
❑ NEW HOME CONSTRUCTION O ADDITION
8'IvIAINTENANCE/REPAIR ❑ REMODELING
ROOFING /S
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED NEIGHT:
SIDING
� Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
'��=° i:%t.
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACNED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
STATE ZIP_
�= c�c�.s -
dI'G'i S STATE ZfP
WiDTH HEIGHT
FT
BASGMENT REMODELING SUBMI r:
1. Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDTNG D�CKS.
ADDI7�lONS, & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed proiect.
2. Two sets of construction plans
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:
��USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ j`--�=-`'�"; `� 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
$ �� _ ,� �j See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ ; c °• .001 times the total job valuation
$ j,� .0005 x Permit Valuation Minimum $5.00
$ '�� 1 $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC far determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ � i I , �7 Make checks aavabie to: Citv of Fridlev Attach Stiaalations
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 odes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application pe it and w� is not to start without a ermit on site; that the work will be in accordance with the
approved plan in the case o 1 whi re ui e view and approval of pl� � /
v
SIGNATURE OF APPL]C.ANT' -- �-.� � P�INT NAME_� /� � a �' - c-� �L'%cd� �'� DATE �_'� � /1
aPPROVALINSPECTOR SIGNA� RE ,_ �� --�; � l�:%/ ' /�. .�%
�, � �i �� �7