P - 35748Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_�'J[;�C / "��C�
SITE ADDRESS fS:
THIS APPLICAI3T IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE t-I-2011
ADDRESS ��l/It_,° �
❑ OWNER �CONTRACTOR
ADDRESS: [53�0 �o`�' `$�n s{�-- CITY
PHONE: ?i�'3 � STI- 6'� I7
Permit No.: � � �
Received By:✓� t
, • - �;I i�r � Y �t. .. �d i.
. .
STATE�ZIP SStj 3 AL
NAME: / �rea re
STATE LICENSE # $� LEAD CERT NCJMBER
ADDRESS: �C'S. BOk �i Fi � CITY d$SC� STATE�,�IP��; �3�'�
PHONE ?�' o� 3B '� S 3 FAX �' 3� 32�1 •�S'��o
� SINGLE FAMILY/NEW CONSTRUCTION S[ZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
� ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT F[NISH � ROOF ❑ DRAIN TILE
❑ DECK p SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR � REMODELING
��., r�,o a i?.� .,1 , � <L - •- � ►a < A/'�. d� _ ..L
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
O Vinyl
❑ Aluminum
❑ Other
❑ HOUSE ONLY
f�HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
BASEMENT REMODEL(NG SUBMIT:
1. Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDiNG DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two seu of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENIIJG CHANGES &
TYPE OF WINDOW TO BE MSTALLED NUMBER OF WMDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�,C�C)O• "° OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$ b
$
$
$
$
$
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 Fridlev
Attach Stiaulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL 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 for a p ' 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 of all equires review and approval of pla s n
SIGNATURE OF APPLICANT PRMT NAME ,�v1e ,� /M�n ( i'1 � DATE__,���oC�
APPROVAL 1NSPECTOR SIGNAT _ —�— �