P - 39648Building
Inspections
763-572-3604
763-502-4977 F
DATE �`
SITE ADDRESS _
THIS APPLICANT IS
BUILDING
RESIDENTIAL APPLICATION
_?-� �
�/o� �.l��l��
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.:Zc�l 1 � ( 7� "
Received By: � _
Date Rec'd: ���i (
YOUR E-MAIL ADDRESS .� yL�vl �/. J la��'�c",f� �d1C ;(Z? Y'�
❑ OWNER � `�'�ONTRACTOR
NAME: tF" l�c� c'!S
ADDRESS:_ ,��-�(�G? l7jLKc�-�
PHONE:�,j -- �I� — J� !
NAME: ��`✓c°6�'✓' . ..�i?C:
STATE LICENSE # �CYo�3 7'v� 7 �
Ai�DRF.�S' %� �/r'�� �'�..,
PHONE �/� — //b'— Yl �
J7�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
CITY
ATE�ZIP �7 ��
LEAD CERT NUMBER
CiTY ��� STATE�ZIP J3 � �Z
F�c �577 - f��9 3�3 7
SIZE
PERMIT TYPE � �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �-'ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SW]MMfNG POOL
TYPE OF WORK: I❑ N6W HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR �REMODELING
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING F
NUMBER OF SQUARES o�G'
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
S[DING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTiNG OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENRJG CHANGES &
TYPE OF WiNDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
0 Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
WIDTH _ HEIGHT
FT
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor pian
3. List of strucLural members to be used
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADDITIONS & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two seu of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE SASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL 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
Total Due
$ �j. 'S'
$
$ ,
$ �� )-T---
$ ��"2_.._
$
$
$
$
$ l 0'1 • CQ `7
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the tota] 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 oavable to: Citv of Fridlev
Attach Stipulations
THIS IS AN APPLICATION FOR A AERMIT-NOT VAL[D 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 codes of the Ciry of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a ermit and work is not to start without a permit on site; that the work will be in ac rd nce with the
approved plan in the case of alt o whic es review a� pproval of plan . j ,./�� /� �� 1
SIGNATURE OF APPLICANT ��--�" ��[ eRINT NAME_� ��l�l vi � Lt��OF' % DATE I