P - 48074Building
Inspections
763-572-3604
�63-502-4977 FAX
DATE ' I ' �
SITE ADDRESS ��
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBNIIT A COPY OF
YOUR STATE LICENSE
Arm c��ca� oF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
�rYrE oF woKx:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE l 1-2011
YOUR E-MAII. ADDRESS
❑ OWNER
NAIvtE: � � 1�
ADDRESS: GJ� L
PHONE: —1 lQ �
NAME:
STATE LICENSE #
PHONE I l0 � S• �/ 1' l 1��
❑ SINGLE FAMII.Y/NEW CONSTRUCITON
❑ TWO FAMII.Y/NEW CONSTRUCITON
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
a Mnnv�r�nrrc�rnm
nESC�E woruc BmvG norr�:
❑ SIDING
LEAD CERT NUMBER
[ 1� CI'I1' �
> Fnx ' I�
SIZE
STORIES
'ISHED ❑ WINDOWS
0 DRAIN TII.E
❑ OTI�R
NG POOL
❑ ADDITTON
❑ REMODELING
---- � r '—'-'--
Permit No.:
Received By:
Date
�
ROQFING ❑ HOUSE ONLY BASEMIIdTT REMODFddNG SUBMIT:
NUMBER OF SQUARES O HOUSE & GARAGE 1 Existing Floa, P�
GARAGES /��� � ATTACHED GARAGE 2. Ptop�ed flo� plan
PROPOSED SIZE: o[.JC � � DETACHED GARAGE 3. List of stmctuial members ta be usod
PROPOSID HEIGHt�7�'.���.� yJl �[d.�' Q �'�{ 6
�ING � � � Ja`� � �Lj �`�3� � W CONSTRUCTION Il�iQ.UDING DECKS,
❑ Vuryl �Soffrt SIDING/SOFFIT/FASCIA DITIONS_ & PORCFIES SUBMiT_
❑ Aluminum ❑ Trim REMOVED? 0 YES 0 NO 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia � P�P� P�J�
2. Two sds of c�sh� plans
WINDOWS 3. Faeagy Calcuiatioos
IN EXISTIlJG OPEIVINGS OYes ONo LOCATION OF WINDOWS FOR W[NDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPIIdINGS-DESCRIBE SIZE OF MANUFACPIJRE STICKER ON WINDO�V.
OPENING CHANGES 8c
TYPE OF WINDOW TO BE INSTALLED NUMBER OF YVINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
^�� (�T�SING 1'�IE 1997 U.B.0 FEE SCAEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surchazge
SAC Charge
Ctub G�t F.scrow
Erosion Control
Park Fee
Sewet Main Charge
Totat Dne
$ '� 1"I � `� See Back Page for Fee Schedule
$ 65% of Buiiding Pecmit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valua6on Minimum $5.�
$ $5.00 (State Licensed Resid�tial Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=5
$ $450 Conservation Plan Review
$ Fee netermined by Fngine�ring
$ Agreement n�essary ( ) Non Necessary ( )
THIS IS AN APPLICATION FOR A PIItMIT-NOT VALID UNTII. PItOCESSED
I hereby apply for a building peimit and I ac�owledge that d►e information above is complete and accurate; that the work will be in
conformance with the ordinanc d cod� of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicati fo a permit and �v k is not to start without a pennit on site; that the work will be in accordance with the
approved plan in the case of 6r1 hic t�t ' approval p� �e�
SIGNATCTRE OF APPLICANT P NAME IrU DATE ��` �' t�
APPROVAL INSPECTOR SI A
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