P - 46816Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � �' ` 3 '� 1 �
SITE ADDRESS J�-�� S
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-20ll
i .A��-f-�C
O OWNER
YOUR E-MAIL ADDRESS
� .� r�/2_
OCONTRACTOR
Permit No.: �� � ��
Received By: ��
Dat����d� � ����
PROPERTY OWNER/ NqMg: �t`�
TENANT qDDRESS: CITY STATE ZIP
PHONE:
CONTRACTOR N�E. • r. /h C8 n� S
' SUBMIT A COPY OF STATE LICENSE # C�L.� ��3 �� LEAD CERT NUMBER
I YOUR STATE LICENSE � t� r; CITY %Y� ��/�-� � STAT w ZI _�'�
AND CERTIFICATE OF ADDRESS:�o�`� � S� • S O�i 'v r- ✓J L� �
INSURANCE PHONE F�
PROPERTY TYPE
PERMIT TYPE
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE_
O TWO FAMILYMEW CONSTRUCTION STORI]
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE:
ROOFING , �'�
' NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT: _
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
W INDOW S
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WTNDOW TO BE INSTALLED
❑ GARAGE/SHED ❑ WINDOWS
❑ ROOF ❑ DRAIN TILE
❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of struc±ural members to be used
FOR NEW CONSTRUCTION lNCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT:
1. 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.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 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
$ `�,� � �
$
$ '2 t���
$ `f � U�
$ C �1 iT—
$
$
$
$
$
$ � ..�� �
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 Sti
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 it an work is not to start without a permit on site; that the work wil] be in accordance with the
approved plan in the case �f �llj.w�c ic ' es review and approval of,pl� � Sn,� �[ � J DATE ��—�`��
SIGNATURE OF APPLICANT `�U �� PRINT NAME1�� 1` T
APPROVAL INSPECTOR SIGNATUR� , �T,,, , �,.;,,.��� „����,; �, ������,. „_ «; . �s'.;
_ ... . . . � �t ___,�� _ __ ._.......x�r,�.� � r�