P - 44538Building
Inspections
763-572-3604
763-502-4977 FAX
DATE `x - , 7' �% �
SITE ADDRESS �.y"�•
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER �CONT
NAME:��l;1� 1"11 I I �-'r
�
ADDRESS: '7�
PHONE: i�Lr��.���!���
NAME:�i� n
STATE LICENSE # ,�i `f� t G,�
CITY
CERT
CITY
- 7 t.� O� 1.4; �� a FAX
�"SSINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF ❑ DRAIN TILE
❑ DECK SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
�� � �� 8 / �
LENGTH WIDTH HEIGHT
ROOFING -1Z���/
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING � ��
❑ Vinyl
❑ Aluminu
� Other+��t�.�
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
ALL FEES ARE BASED ON V
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
❑ HOUSE ONLY
�iiOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
Permit N
Received By��
Date Rec' d:.�/�
STATE��iP
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS_ & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two seu of construction plans
3. Energy Calculations
LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
NUMBER OF WINDOWS
�LUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�I�IG THE 1�7„U,�SC FEE SCHEDULE)
$"/ % if (, GJ � 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 ( )
$ i N�_ Make checks navable to: Citv of Fridlev Attach
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 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 Qf �11 work w ic re uires review and�bproval ofp,lans`�L I ��.��� DATE y�i�� /�� �/
SIGNATURE OF APPLICANT R�� 1r7iC'��� � O�.� /"��. �1�RINT DY�ME��li�l�'3"➢l�l P� i�