P - 47353Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �' I UJ'`�
SITE ADDRESS _�
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
E-MAIL
� OWNER
rra�: �1 ��1�, r� �
aDn�ss:_!? G��ji�t c�le°'1 57"!v
PHONE: ��(�',� ' � !,� .� �J.J IJ
STATE
i7/�:�Tt�°�
SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCT'fON
❑ ADDITION ❑ ARAG
❑ BASEMENT FINISH �OOF
❑ DECK ❑ SIDING
❑ SWINIlVIING
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ A
❑ MA1N'TENANCE/REPAIR j�'`R
DESCRIBE WORK BEING DONE: � j
SIZE OF IMPROVEMF;N"I' LE GTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES / 7, 33 �'HOUSE & GARAGE —7
GARAGES �ATTACHED GARAGEI�
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
G.
SIZE
Permit No.:
Received By:
�, '�- � � �
STA
CERTNUMBER �1f H"/ - G��-5'/1S"
CITY ��UIl�,�?jte �1�. STATE%V
X 7�3-7�'� --t�G���
❑ DRAIN TILE
❑ OTHER
HEIGHT
FT
JTS �Z/
�.�.5 YZ
BASEMENT REMODELING SUBMIT
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS_ & PORCHES SUBMIT
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPEIdINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFAC'TURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NLJMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
� (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION S U1,.5l�, ��-� 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
$�J}i�� See Back Page for Fee Schedule
� 65% of Building Permit Fee
$ q .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
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID iJN'TIL 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 permit and 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 w k hich re i s review and approval of plans. ,, } /'� f,�
SIGNAT[JRE OF APPLICANT �r���.n � y� pRINT NAME `�`�'��i1��✓1 �Gil�?M✓I DATE c.9'��W �1 /
APPROVAL INSPECTOR SIGNATURE �� ^�--