P - 40842�
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ' � � • �l
SITE ADDRESS _���
THIS APPLICANT IS:
PROPERTY OWNER/ �
TENANT �
CONTRACTOR
SUBMIT A COPY QF
YOUR ST'ATE LICENSE
AND CERTIFTCATE OF
INSURANCE
PROPERTY TYPE
�
BUILDING �'� �. '�v�
RESIDEN�IAL APPLICATION
CITY OF ;F��.tIDLEY
EFFECTIVE 1-1-20ll
E-M.AII:
❑ OWNER � �ONTRACTOR
A . . � �
A�DRESS: ,�S S
PHONE:��
NAME:
STATE LICENSE #
r
'7
rtt�N r, �.> r~ � o`t-- �.Co �-f' li
�0'�INGLE FAMILY � N
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ ADDITION O GARAGE/SHED
❑ BASEMENT FINIISH IsYi�00F
❑ DECK ❑ STDING
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION O ADDITION
DESCRIBE WORK BEING DONE: f�
SIZE OF IMPROVEMENT
R OFING
NUM$ER OF SQUARES __ � 3
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
O Vinyl
O Aluminum
❑ Other
wn�mows
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENF1VCiS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
ALL FEES ARE BASED ON V
COTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Ghazge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Dae
❑ HOUSE ONLY
�+J-IOUSE & GARAGE
❑ ATTACHED GARAGE
0 DETACHED GARAGE
❑Soffit
❑ Trim
� Fascia
LOCATION OF WINDOWS
J,• J�i}�'
r�c�
�
EAD CERT NUMBE
CITY
FAX IOSI -' % �
SIZE
STORIES
O VJINDOW S
l7 DRAIN TILE
❑ OTHER
�
H HEIGHT
SCHEDiJLE)
Permit No.:
Received By: (r �
Date ���: � � � � � t �
,STAT�ZIP �
� � �
STAT�_ZI
- 90 Se
FT
BASEMENT REMODELING SiTBMIT�
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
AADITIONS & PORC � Si MIT'
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
MANUFAGTURE ST'ICKER ON WINDOW.
MATERIALS:
TYPE
�� �` , See Back Fage for Fee Sah�dule
__
$ _ 6S% of Building Permit Fee
$ � • .001 times the total job valuation
$�--- .0005 x Permit Valuation Minimum $5.00
$ SLV _S. �i $5.00 (State Licensed I�esidential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+5ft= ftx$24=$
$ $450 Conservation Pian Review
$ Fee Determined by Engineering
$ s Agreement necessary () Non Necessary ()
$ Make checks a able to: Ci of Fridley AttacL
THIS IS AN APPLTCATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building perrnit and I aclmowledge that the infonmation above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the C'ry of Fridley and with the Minnesota Construction Codes; that T understand this is not a
permit but only an app]ication For a permit and k is not to start without a permit on site; hat the work will be in accordance with the
approved plan in the case of Il c whic req ' re iew and approval of plan�, ,�/ ��� ��
SIGNAI'URE OF APPLICANT PRINT NAME '�� �-(,. V D�'I Dn�
APPROVAL INSPECTOR SIGNATIIR . •