P - 39369Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ���'0 � � o�� � �
SITE ADDRESS _
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-I-201I
E-MAIL ADDRESS
❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: !/;�tc�.._ t�Sl t�w°�G.vr� �Zcz,.r��,��
TENANT 'n- ''
ADDRESS: S��`-I if.s�-,�.�� CU�- CITY
�
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
NAME: �; e
STATE LICENSE # i� LEAD CERT NUM
ADDRESS: ��b i � ��T �� ` ��`�� CiTY
PHONE � I�- �i O'' 2'� �,i } FAX
PROPERTY TYPE I� SINGLE FAMILYINEW CONSTRUCTION SIZE
t" d TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT F[NISH �I' ROOF /� ❑ DRAIN TILE
❑ DECK �(S1DiNG I``��� ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�f MAINTENANCE/REPAIR ❑ REMODELING
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
�
ny� ���
Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
�-
Permit No.: � r �Y
Received By: ' �
Date Rec'd: 7' /
ATE%I(�= ZIP SS� I
ATE/�'i/+✓ZIP
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDTNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. Site Pian/Survey showing the existing structures
and proposed project.
2. Two sets of conswction 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:
SING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB �ALUATION $ ��%� aU 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
- $ �,�,3�.��r
$
$ ,� 7.�
$ � �9
� b�
$
$
$
$
$
$ .
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 aavable to: Citv of Fridlev
Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby appiy 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 in accordance with the
approved plan in the case of all wh'c r� 'res review a approval of plan-�s-7� / ��� �
SIGNATURE OF APPLiCANT ��--� � PRi T NAME (�}�l �� � l� DATE � `�
APPROVAL INSPECTOR SIGNATURE /� %—, � �-