P - 40729Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�/ eG(/�
STTE ADDRESS �
'fH1S AYPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVF, I-I-201 I
YOUR E-MA[L ADDRESS
❑ OWNER �CONTRAC'fOR
Permit No.
Received By: �l� �
���:�� 2 2 �Oi�
PROPERTY OWNER/ NAME: e `
TF,NANT ADDRESS: SO^OOr p CITY STATE�ZIP ss���
PHONE: G�.0 � J ` ,3 / � _/_
CONTRACTOR NAME: �O �+ ��' I
SUBMIT A COPY OF STATE LICENSE #� C J LEAD CERT NUMBER — t OT "
YOUR STATE L�CENSE
AND CERTIFICATE OF ADDRESS: � S rV � CITY CK- STATE,�Z1P��
TNSURANCE pHONE Cf - Yyy FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCT[ON STOR[ES
PERMIT TYPE
TYPE OF WORK:
❑ ADDITION ❑ GARAGE/SHED ❑ WiNDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DF,CK �S`iDING � OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDiTION
❑ MAINTENANCE/REPAtR .�REMODEI,ING
DESCRIBE WORK BEiNG DONE:__�
SiZE OF iMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
inyl
❑ Aluminum
❑ Otl�er
LENGTH
❑ HOUSF, ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
FT
BASEME[VT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of s[ruchiral mcmbcrs [o bc uscd
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITiONS. & PORCHES SUBMIT:
❑ Trim 1. Sitc Plan/Survcy showing thc cxisting st�UC[ures
❑ Fascia and proposcd project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRTBE S1ZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE iNSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, iNCLUDTNG THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �� OO�, O G OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Stucharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$
$
$
$
$
$ . , - -
See Back Page for Fee 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 APPLTCATTON FOR A PERMIT-NOT VALID UNTIL FROCESSED
I hereby apply for a building permit and I acknowledge that the inforn�ation 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 pe�7nit on site; that the wark will be in accordance with the
approved plan in the case o� ��' w requires review and approval of plans. /� �
SIGNATURE OF APPLICANT ��,��" �� PRINT NAME �d'��'1 /Li%'� Z DATE ���� I� O I/
APPROVAL INSPECTOR SiGT�tiTURE