P - 43033Building
Inspections
763-572-3604
763-502-4977 FAX
DA� i o t2
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER
rxor�: 7b�' S`ZC- ?CE33
CONTRACTOR NpME: . ,�e �'us f�r/� f
SUBMIT A COPY OF STATE LICENSE # Z d'3 �`7 �L IaG] LEAD CERT NUMBE�
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: �� 17 .��' Cfi , ri[ 6 CITY�C
INSURANCE PHONE �G ' S7 �E" gZ L� FAX �Z ^��
PROPERTY TYPE ,�i7'SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/I3EW CONSTRUCTION STORIES
PERNIIT TYPE ❑ �DTI'ION ❑ GARAGEJSHED
❑ BASEMENT FIAiISH �'1FOOF
❑ DECK ❑ SIDING
TYPE OF WORK: � NEW HOME CONSTRUCTION ❑ ADDITION
6�'1G�t11NTENANCFJREPAIR fl REMODELING
nESCx�E woxx sm�rG vorrE: a,� o� o�cL 2r�1 �nS(2C( ll�t'w �
SIZE OF IMPROVEMEN'C LENGTH WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES Z� ❑ HOUSE 8c GARAGE
GARAGES
PROPOSED SIZE:
PROPOSID HEIGHT:
SIDING
❑ Vinyl
❑ Aluminwn
❑ Other
❑ ATTACHED GARAGE
O DETACHED GARAGE
❑ DRAIN TILE
O OTf�R
Permit No.;
Received By:
Date Rec'd:
ATE��%ZIP��Y,�
'�,,1-1 $3iS^ fd�
' ��
BASIIvIIIVT RF.MODII,ING SLn3MIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of struchual members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit �9�DITIONS_ & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the exisdng structures
❑ Fascia � pro�� p���'
2. Two sexs of con4huction plans
WINDOWS 3. Energy Calculations
IN EX[STING OPEriINGS OYes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES 8c
TYPE OF WINDOW TO BE INSTALLID NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ _ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Comrol
Park Fee
Sewer Main Charge
Total Due
$ (�' �,75 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ ? .001 times the total job valuation
$ .0005 x Pennit 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 ( )
S 'l . U. D Mske checks uavable to: Citv of Fridlev 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 complete and accurate; thai 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
pernut 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 11 wor ic equires review and approval of lans.
SIGNATURE OF APPLICANT �_ P�,,,� PRINT NAME�tN �� D�'N GE �' DATE `0 j 2 ��
APPROVAL INSPECTOR SIGNATURE
PLEASE NO'IE: SEPARATE PERMTTS ARE REQUIltED FOR PLUMBING, ELECTRICAL AND ME�HANICAL WORK
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