P - 36743Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 1r-/?5� �K �`�.�J
SITE ADDRESS �� 3 0
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF
BUILDING
RESIDENTIAL APPLICATION
❑ OWNER
��i� s:
PH E: 5
Permit No
Received By:
��
CITY OF FRIDLEY Date Rec'd: ��i
EEFECTIVE 1-1-2011 ��� ���I ���
� ` �
_ YOUR E-MAII. ADDRESS ��t,i'�v�o1-�-�ev� CQ��(�c� wt,Qc\.. LO �
� L ��r : ���.�e � v� � � �t3 2, --�
�CONTRACTOR
����1 �' �M� �-
'�� ' L. �l, �CITY � ���''C-� STATE � k ZIP 5 u� �
STATE LICENSE # L.NJ(p S L[ (.
ADDRESS: �i� « 4L� �'I � �
LEAD CERT NUMBER
CITY V� STATE�I�IZIP_��33b
PHONE (p �`L. 'Ti�L 1 �`(.b '� FAX
�SINGLE FAMILYMEW CONSTRUCTION S[ZE
TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ,� ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION . ❑ ADDITION
❑ MAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE: 1��
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 &
TXPE OF WMDOW TO BE INSTALLED NUMBER OF WINDOWS �
D ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
OCCUPANCY TYPE
❑ HOUSE ONLY
� HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
ALL FEES ARE
TOTAL JOB VALUATION $
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDING DEGKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/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.
$ `� ).ol � See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ �'jQ� $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (P(ans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary (
$ I i�i�l�%`I Make checks pavable to: City of Fridlev
Attach
THIS [S AN APPLICATION FOR A PERMIT-NOT VAL1D 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 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 w which requires review and approval of pl ns / f
SIGNATURE OF APPLICANT PRiNT NAME ��oj I'� DATE �/ a/ �l
APPROVAL INSPECTOR SIGNA�"URE