P - 48401Building
Inspections
76�=5�2-3604
763-502-4977 FAX
DATE ,,� c�.�Q_ Z 7, Z
SITE ADDRESS �� %�T7
THIS APPLICANT IS?��
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
�1
I-e�'%.e%5'�s-✓ S
❑ OWNER
NAME:1 P� cF�
ADDRESS:�
PHONE:
NAME: V�n
STATE LICENSE #
ADDRESS: ld��
YOURE-MAILADDRESS �I�nnoC.hi1���,�ldU
a.r_-
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CITY
CERT
CITY
PHO�IE S�" Z��' — S� S� FAX /�3 S%
SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
.�BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MA[NTENANCE/REPAIR �REMODELING
DESCRIBE WORK BEING DONE: /f G C�v�..
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 WINDOWS
Permit No����
Received By:
Date Rec'd: 2� � �
s � 6 ''�'`\
STATE�_�IP � �
� STATE�IP
��i� YC
WIDTH ±� HEIGHT S�� � SO FT
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDTNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed projeci.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL N EES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $���f )-� 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
$
$
$
$
$
$
$
$
$
$
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 payable to: City of Fridley Attach
ulations
THIS IS APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I a owledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of t City of Fr' ley and with the Minnesota Construction Codes; that i understand this is not a
permit but only an application for a permit and ork is n to start without a permit on site; that the work will be in accordance with the
approved plan in the case of ork equir evi and approval of pl s. � e�y
SIGNATURE OF APPLICANT P NT�,IAME ��r,y'�i�/!/1 �r--t DATE �� �(.Z���
APPROVAL INSPECTOR SI „ /G'/
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