P - 35269Building
Inspections
763-572-3604
763-502-4977 FAX
DATE --J L[. `
SITE ADDRESS
TH[S APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-20ll
�
❑ OWNER
�MAIL ADDRESS
(� ___-`i—=�
�CONTRACTOR
oa�
ADDRESS: S� �`Sy l `� [.�Lj �..r.� /Q-�,/tJ�("jTY
PHONE: /lD ,� � g' �d • � ot. 7 �
f�
Permit No.: ' � � �- . . �
Received By: �` �
Date Rec'd: "'� � �
��� ���/��E'_�
STATE ZIP �S ��
STATE LICENSE # ,�� ��{ ��;� � LEAD CERT NUMBER_
ADDRESS: �C9�.7 G)� KpiS� /Q-L�., � CITYi�� .2 STATE�LIP S�� �
PHONE � l 2- "' L/ S� � oZ � 7� FAX `%'o _��– S y�s ^ IO�o ,�'
❑ SINGLE FAMILYMEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ BASEMENT FINiSH
❑ DECK
TY.PE OF WORK: ❑ NEW HOME CONSTRUCTION
❑ GARAGE/SHED ❑ WINDOWS
❑ ROOF O DRAIN TILE
❑ SIDING ❑ OTHER
� SWIMMING POOL
DESCRIBE WORK BEING DONE: ��r l31.--GL �'-G ✓'
SIZE OF IMPROVEMENT f .F.NC:TH
ROOFING
NUMBER OF SQUARES oZ.�
GARAGES
PROPOSED SIZE:
PROPOSED H�IGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ ADDITION
❑ REMODELING
❑ HOUSE Oi�(LY
� HOUSE & CARAGE
� ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
�i 2--
T—
HEIGHT SO FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two seu of construction plans
3. Energy Calculations
FOR WINDOWS – PROVIDB U-VALUE AND
MANUFACTURE STICKER ON WINDQW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING�'HE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ G,�• a 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
rr'—' .
�`
��
���
r1�ll�IL�
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 Pian Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks uavable to: Citv of Fridlev
Attach
THIS [S 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; that the work wi11 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 ermit d 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 work w'ch r quires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME DATE
APPROVAL INSPECTOR SIGNATURE P —