P - 41393Building
Inspections
763-572-3604
763-502-4977 FAX
�:
DATE ���,� -
SITE ADDRESS � �
THIS APPLICANT IS:
i PROPERTY OWNER/
TENANT
i
' CONTRACTOR
SUBMIT A COPY OF
, YOUR STATE LICENSE
AND CERTIF]CATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK
DESCRIBE WORK BEING DONF
SIZE OF IMPROVEMENT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-I-201I
YOUR �-MA1L ADDRESS
; r'L'��;1 11 ( 't'
O OWNER OCONTRACTOR
` � l:, , �- _, [.
ADDRESS: � j C'�J � �L _i�-,��.�i�j; , C1TY
PHONE: i/_ :.. t_:� J� �'� s. ��.
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NAME: � L� I�—L �• �� 5 tl`�� �j� �� 4 LL
STATE LICENSE # Z ��, �� � 7� S� LEAD CERT NUMBER
ADDRESS:�C% � %S Gz�'t��%� I'. CITY���%ti
PHONE (- ( Z _ l%I �_ C� �(i % FAX
❑ SiNGLE FAMILY/NEW CONSTRUCTION SIZE
� TWO FAMILY/NEW CONSTRUCTION STORIES
� ADDITION ❑ GARAGE/SHED �W'INDOWS
❑ BASEMENT F1N1SH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
� SWIMMING POOL
❑ NEW HOME CONSTRUCTION O ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
i. L.� i �' ��(.`i;`� i�
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZ.E:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
VI'INDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF W(NDOW TO BE INSTALLED ;�_� ,>
LENGTH WIDTH HEIGHT
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
�.� •� �"NUMBER OF
--�
Permit No.:%_( ' �, �' '
Received By: . � � ��
������ :� (1 2 0 �?
STATE��ZIP < <
'" (�, I �� �L; L f .- (
��STATE�IP S c`%i
FT
BASEMENT REMODELING SUBMIT:
I . Existing Ploor Plan
2. Proposed floor plan
3. List of struc!ural members to be used
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADDITIONS & PORCHES SUBMIT:
l. Site Plan/Survey shoti�ing the existine structures
and proposed project.
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 �'�I� 1997 U.B.0 FEE SCHEDULE)
I'OTAL JOB VALUATION $ _/_�'/ jL� _ 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
$ /y��l .�: L.? See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ f�"� i' .001 times the total job valuation
$ �� Z .0005 x Permit Valuation Minimum $5.00
$ �->��� $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ �+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Detennined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ f'- .,' `� Make checics aavable to: Citv of Fridlev Attach
lations
THiS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
[ 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 permit and work is not to start without a permit on site; that the work will be �n accordance with the
approved plan in the case of all �Gbrk�/ ic�, /', e uir s review and approval of plaq �i � � �'
SIGNATURE OF .APPLICANT ��; /4 f C�} � ,� PRINT NAME `Y� "c� � � %�c:� ll °`�(�'j�� DATE � �".% l�
aPPROVAL 1NSPLCTOR S1GNA1'UkE '
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBI�G, ELECTRICAL AND 1VIECHANICAL WORK