P - 36733Building BUILDING Pernut No. �t�' '° ��� ��-
Inspections RESIDENTIAL APPLICATION Received By: _
763-572-3604 CITY OF FRIDLEY �at��d�i B�� �, �� 8��
763-502-4977 FAX EFFECTIVE 1-1-2011
na'rE � �- 1�t � Zc� \\ YOUR E-MAIL ADDRESS C'� H R�VT,O� (� 3[E% iR (Yl N,� a��.
srrE �D�ss C,. S'? c'l 1� �� nc, C�- N. I; . �i�.� a�AU 1�Y11�1 s�W '� �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
I' sulM � '
��[I�1�',� ;�
�ZSVJNER �CONTRACTOR
PHONE: %ia3 � ��N"v(�o �Q 7
STATE LICENSE #
PHONE
�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAI�III.Y/NEW CONSTRUCTION
0 ADDTI'ION ❑ GARAGFJSHED
❑ BASEIv1EN'f FINISH �f'FROOF
❑ DECK ❑ SIDING
❑ SWIIvIIvIING POI
0 NEW TiOME CONSIRUCTION ❑ ADD
�mn'ExaivC�r,�ut ❑ xEM
r�ESCCx�� woxtc B�rG norrE:
NMB� OF SQUARES ��
GARAGFS
PROPOSED SIZE:
PROPOSED HEIGHT:
�
❑ Vinyl
O Aluminum
a or� �
�FIOUSE ONLY
❑ HOUSE & GARAGE
� ATTACf�D GARAGE
❑ DEl'ACHED GARAGE
Osofftt
D Trim
❑ Fascia
wnvnow�
IN EXISTING OPENiNGS OYes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
� WINDOW TO BE INSTALI.ED NUMBER OF WiNDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE
(USING THE 1997 U.B.0 FEE SC.
'OTAL JOB VALL
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb C�t Escrow
Erosi� C�trol
Park Fee
Sewer Main Charge
Total Dae
� r� C �
v �
S
$
$
$
$
See Back Page
65% of Buildir
.001 times the i
.0005 x Permit
$5.00 (State Li
$2230 per SAC
ft+6 ft
$450 Conserva
Fee Determina
Agreement nec
THIS IS AN APPLICATION FOR A PERMIT ]
I hereby apply for a building permit and I acknowledge that the inform
conformance with the ordinances and codes of the City of Fridley and with
petmit but onty an application for a permit and work is not to start witho�
approved plan in the c�se of all }ay���ires review and approval of
SIGNAT[IRE OF APPLICANT �� _ ,--------'> PRINT NAME
CITY
STATE_� %�ZIP S�'�1,��_
CERT NUMBER
ATE ZIP
FAX
SIZE
❑ WINDOWS
❑ DRAIN TII�E
❑ OTHER
E������1��i��1 � Rl;.`���� �
�� �
,�, i,�
, �, �
FORNEW CONSTRLJCI'ION INCLUDING DEGKS,
ADDTfIONS. dt PORCHES SIJBMlT:
1. Site Pl�/Sutvey s6orvring the existing slructures
aad Pr� P�.1�
2. Two sets of c�st�on pi�s
3. Bnerg,y Calculetioa4
FCXt WINbOWS — PROVIDE U-VALUE AND
MANUFAGTURE STICKE'R ON WINDOW.
OF LABOR AND MATERIALS:
for Fee Schedule
; Permit Fee
�tal job walaation
Valvation Minimum �5.00
ensed Residentiai Contractors)
Unit (Plans to MWCC for determiaation)
= ft x $25= $
ion Plan Review
' bY ��g
ssary ( ) Non Necessary ( )
�T VALID UN'I�. PROCESSID
on above is c�plete and accurate; that the work will be in
e Mmnesota Construction Codes; that I undeistand this is not a
a permit an site; that the work will be in accordance with the
F�