P - 35789Building
Inspections
763-572-3604
763-502-4977 FAX
DATE r �
�
SITE ADDRESS
I IJ, LF.`L� �� LKJ� i L� by I
PItOPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
pESCRIBE WORK BEING
STZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
P� SIZE:
PROPOSEA HEIGHT:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
E-MAIL ADDRESS
C�7
STATE LICENSE #
',W CONSTRUCTION
CONSTRLJCTION
❑ BASEMENT FI1dI5H
❑ DECK
�IEW HOME CONSTRUCTION
MAINTENANCFJKEPAIR _
Pe��t No.: '� ( I� I I 3
Received By:
D��°a� ��
�
LEADCERTNUMBER T.LS���ID'
� , CITY � TERTEi1
FAX T(�.� � t� 7 ,� I�
SIZE
STORIES
's/SHED ❑ WINDOWS
0 DRAIN TII.E
❑ OTHER
NG POOL
❑ ADDTI'ION
❑ REMODELING
0 HOUSE ONLY
❑ HOUSE & GARAGE
C] ATTACHED GARAGE
❑ DETACHED GARAGE
'1P �.
f�.�
FT
��$F.1��IT REMODELING SiJBMIT:
i. Facisting Flaor Pisn
2. Proposod floor plan
3. List of struchusl members to be usod
SIDING POR NEW CONSTRUCTION INCLUDTNG DECKS,
�inyl ❑Soffrt ADDITIONS_ & �ORCHES SUBMIT:
Aluminum ❑ Trim 1. Site Plan/Survey showing the earisting structures
and proposed projact.
Other ❑ Fascia 2. Two sets of constcuction plemg
wuvnaws 3. Energ}+ Calculatio�s
IN EXISTING OPENINGS OYes ONo LOCATION OF WINDI�WS FOR WIAiDOW3 — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZfi OF IYfANUFACTURE 5'FICKER ON WINDOW.
OPENING CHANGES 8c
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUAT�ON, INCLUDING THE COST OF LABOR AND MATERIALS:
5r Q7�Il�TG THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION S J V 11.� OCCUPANCY TYPE
Permit Fee
Plan Revi�w
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrnw
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ 1a S� d5 See Back Page for Fee 3chedule
$ 65% of Building Permit Fee
$ .00I times the total job valuation
$ .()005 x Permit Valuation Minimum $5.00
$ �'j O $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ffx$25=$_
$ $45Q Conservation P'lan Review
$ Fee Determined by Engineering
$ Agreament necessary ( ) Non Necessary ( )
$ `Z .S Make checks oavable to: Citv of Fridlev Attach
THIS IS AN APFLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building pernut and I aclmowledge that the information above is complete and accurate; that the work will be �n
conformance with the ordi d codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applica o a ' 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 o ic uires review and approval of pl�s. ��� �� � I',� ��� _!,
SIGNATURE OF APPi.ICANT PRINT NAME i��P "15ATE