P - 48395Building
Inspections
i 63-5'; 2-3604
763-502-4977 FAX
DATE�-,— �_�
SITE ADDRESS �
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR E-MAIL ADDRESS
� �'rl,�v N��v, S_5`fj
❑ OWNER � PfCONTRACTOR
PROPERTY OWNER/ N,�NtE:
TENANT
ADDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF [MPROVEMENT
ROOFING
NUMBER OF SQUARES c�'`
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
�
NAME:�IG; l ( a
STATE LICENSE #
ADDRESS: I%LSG'
PHONE �� — '� ��`/��,
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH C�ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODFyL
Ji. . ✓ � ., .'�'y�
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
CITY
Permit No.: ' ' C , �
Received By: L.
��e� ��. . .
STATE l �l�il ZIP
CERT NUMBER
�c►TY�iii)Al�r��lc,ti� sTaTEf�zrp _SS`' !
F� _�,�^� ,. fs �F�.' _
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
�
�� WIDTH __�j" r HEIGHT ?� � SQ FT
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
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:
L Site Plap/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:
(itJS�ING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $,;[(7�L� %� _ 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
$
$ >
$ �,
$ ,..�
$
$
$
$
$
$ f ,
��'-�
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 Stipulations
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 permit and wark is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of�11 work'w i h requires review and approval of1� ns. ��/
SIGNATURE OF APPLICANT ���6A��_.,. ,- PRINT NAME t\U �I I�l���CL.ft�4a DATE �...�` �__ j�
APPROVAL INSPECTOR SIGNATURE
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