P - 45746Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
SITE ADDRESS _
THIS APPLICANT [S
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER
NAME: ����i 'IliUNIO
ADDRESS: �S�I 1 1-+U C I i�' L�N� u� CITY
PHONE:
DFtAIb
tA
Permit No.: � � �'b
Received By:
�� ,� -, �
STATEM� ZIP �Y3 Z
STATE LICENSE # Z�lo ���j�'I I LEAD CERT NUMBER
ADDRESS: � O I Z l �� I�^�,/ C'_ I�i W CITY ��k V RV�E STATE l�'1NLIP �03
PHONE�G�j r �Z-�I � 3013 FAX
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �[ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SW[MMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR O REMODELING
DESCRIBE WORK BEING DONE:
SIZ6 OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING �"'•: l� ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �,t.� ❑ HOUSE & GARAGE �. Existing Floor Plan
�/
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
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
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/3urvey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE tJ-VALUE AND
MANUFACTURE ST[CKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALOATION $_� 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
$ d��' �'.�
$
$
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Bailding 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
THIS IS AN APPL[CATION 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 applicatio for a pe •mit 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 a il c wh�h reqvires review and approval of plans.
SIGNATURE OF APPLICANT PR[NT NAME S�_ �DATE �'� �" I'
APAROVAL INSPECTOR SIGNATU E