P - 41743Building
Inspections
763-572-3604
763-502-4977 FAX
DATE /�`�Y —/i
SITE ADDRESS (O
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
I CONTRACTOR
� SUBMIT A COPY OF
! YOUR STATE LICENSE
I AND CERTIFICATE OF
' INSURANCE
PROPERTY TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECT(VE I-I-2011
YOUR E-MAIL ADDRESS
�
❑ OWNER
Permit No.:
Received By: ��
Date ��� ��� � `�" �'�
NAMr.: /JG�+C;� (;jGSG.J
ADDRESS: G Z� �'¢j r,v S i CITY ��!J �4'" STATE�ZIP SS"Y3�_
PfiONE: 7� � ` Z!� - �;ZC, 7
C:
vmo
STATE LICENSE # r�� 0�'7 p( ��
ADDRESS: r� S -�'r0 1�.iLG �'i
PHONE L 5� - 7 S�� —� I�
C35I'F�IGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
h�
CERT NUMBER K'(' 1 S
FAX
SIZE
STORi]
CITY �C>S�JLL� STATF��Ii ZIP SS!/ '3
PERMIT TYPE � �DITION ❑ GARAGE/SHED INDOWS
❑ BASEMENT FINISH � ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NE�OME CONSTRUCTION ❑ ADDITION
0'1GtAINTENANCE/REPAIR ❑ REMODELiNG
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT_
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ 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
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. 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 sets of construction 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:
(IIS�ING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $� 04 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
$ a3,5�
$
$ r•
$ .,
$ �l�C.� .
$
$
$
$
$
$ n
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 �avable to: Citv of Fridlev Attach
lations
THIS [S AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 applica ion for a pe 't nd work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case o ork wh ' s review and approval of p s. l
SIGNATURE OF APPLICANT PRINT NAME ��YN4�'f .�D�L�� DATE / D—�--� I
APPROVAL INSPECTOR SIGNATURE