P - 41224Building
Inspections
763-572-3604
763-502-4977 FAX
DATE��(r�
SITE ADDRESS �
THIS APPLICANT I5
PROPERTY OWNER/
TENANT
CONTRACTOR
5UBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE I-1-2Qll
❑ OWNER
10�,3 ��
Permit No.:
Received By:
-�- -
� . � ;,• „ ,� y � �,� '
i
YOUR E-MAIL ADDRESS �1%/'/�, a �f/�'�j��„ey ����//��.J�'�.r,�r���s'.�y��/ifr�
i r so- ---�
�CONTRACTOR
NAME:G/_�¢ /ei7�//
ADDRESS: ��'��7 �C�l � ��__ /C✓�__CITY � �/�La,t,/ STAT��IP,S'��_
PHONE: ��'_ �I��" �S�.Sr
STATB LICENSE #_ �(jO � �% �� LEAD CERT NUMBER /Vi�i- �3 ' / — /
a�D�SS_���>/ �r�s� ts'�.�' Cn'Y .uJ �STAT�2�Lt11P�;�����
PHONE �SI— '�I�S"(>{O._S�_ FAX ��SJ—�/�� .-/%yS"^
I� SINGLE FAMILYfNEW CONSTRIICTION
❑ '['WO FAMILY/I�rEW CONSTRUC'TION
❑ ADDITION ❑ GARAG
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMM
SIZE
STOR.�5
❑ WINDOW3
❑ DRAIN TILE
�QOTHER
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITIQN
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: � SC j�
SI2E OF IMPROVEMENT LENGTH VdIDTH
ROO�'ING ❑ HOUSE ONLY
PTIJMBER OF SQUARES ❑ HOUSE & GARAGE
GARAGES
F'AOPOSED SIZE:
FROPOSED HEIGHT:
�IDING
0 Vinyl
❑ Aluminum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGB
�Soffit
❑ Trim
� Fascia
WINDOWS
LQ EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS
UR FORNEW OPENINGS-DESCRIBE SIZE OF
C�PENING CHANGES &
BASEMENT REMODELING SUBMIT�
1. Existing Floor Pian
2. Proposed floor plan
3. List of structwal members to be used
FOR NEW CONSTRUCTION INCLUDiNG L�ECKS,
ADDITIONS & PORCHES SUBMIT'
1_ Site Plan(Survey showing the existing structures
and proposed project.
2. Two sets of canstruction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALLQE AND
MANUFACTURE STICKER ON WIN��OW.
� TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
'�'OTAL JOB VALUATION $ y� %��Q _ OCCUPANCY TYPF.
F'ermit Fee
F'lan Review
Fire Surcharge
Surcharge
L,icense Surcharge
SAC Charge
Curb Cut Escrow
�.rosion Control
Park Fee
Sewer Main Charge
Tota[ Due
$ 1 l i`� �`� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ C� .001 times the total job valuation
$ - � .0005 x Permit Valuation Minimum $5.00
$ i� $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Detezmined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ 1�' �°�' �� Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PKOCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the w�ork will be in
a�nformance with the ordinances and des of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
p�rmit but only an application fo a pe 't nd work is not to start without a permit on site; that the work will be in accor�ance wvith the
a�proved plan in the case of a ' s review and approval of plaj�/J </� < (�
S=GNATURE OF APPLICANT PRINT NAME ��/Iff(� �C,/`N�t DATE�����
AiPPROVAL INSPECTOR SIGN F. (�