P - 47259Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � t • ..Z I � � �
SITE ADDRESS _�
THIS 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 11-201 ]
YOUR E-MAiL ADDRESS �jvr� `i�c, � l� .Y
S�G..�� �� t��
� OWNER �QNTRACTOR
NAME: C�C�p
ADDRESS:
PHONE: `-}
NAME ..�j L�3rS�� � �_v�
STATE LICENSE #
ADDRESS:
�CLSINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
Permit No.:
Received By:
� . :�;" 3�t� � ` �
TATE � u�- ZIP
CERT NDMBER EXP:
ATE ZIP
SIZE
STORIF—.,4
❑ BASEMENT FINISH ^��VD��nLL
❑ DECK `�OOF
❑ SIDING
TYPE OF WORK: p NEW HOME CONSTRUCTION ❑ SWIMMING POOL
AINTENANCE/REPAIR � ADDITION
O REMODELING
DESCRIBE WORK BEING DONE: �' �� ��,
SIZE OF TMPRl1Vi�'�.,rv�i�r �Z
ROOFING %� ,��}
NUMBER OF SQUARES ��•�
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit SIDING/SOFFIT/FASCIA
❑ Trim REMOVED? ❑ YES O NO
❑ Fascia
❑ DRAIN TILE
❑ OTHER
nntvn 1 $Q FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
Z. 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.
WINDOWS 2. Two sets of construction plans
IN EXIS7TNG OPENtNGS ❑Yes ❑No LOCATION OF WINDOWS 3 Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS - PROVIDE U-VALUE AND
OPENING CHANGES & MANUFACTURE STICKER ON WINDOW,
TYPE OF WINDOW TO BE INSTALLED
ALL FEES ARE BASED ON VALUATION INCLUDING THE COST OF LABOR AND MATERIALS:
OTAL JOB VALUATION $ (USING THE 1997 U.B.0 FEE SCHEDULE)
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
$ VCCUPANCY TYPE
�:3° � � 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+6 ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessa
ry ( ) Non Necessary ( )
$ �,�" Make checks pa able to Ci of F'dl
ri e_ Attact� �tipulat�ons
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LINTIL 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 City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application, a permit and work is not to start without a permit on site; that the work wili be in accordance with the
approved plan in the case of �t1� rk hi uire e' w and approval of
SIGNATURE OF APPLICANT '
APPROVAL INSPECTOR SIG A p�NT NAME {%���%l,[,� DATE l•
� ��� � �:��',,'=�"i "� : , _•; �r3 _ / oZ--�- / l
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