P - 45479Building
Inspections
763-572-3604
763-502-4977 FAX
DATE / ' �
SITE ADDRESS J
TH[S APPLICANT IS:
-Il
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
1NSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEING D(
BUILDING
RESIDENTIAL APPLICATION
�.', sS ( sS i
�9 OWNER
NAME:
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL A[
� i 5�- � � i
❑CONTRACTOR
1/�. J f(a� r] 4�•
ADDRESS: �() 'M i SSt�'�j�c / S T CITY
PHONE: 76 3 " �? ! ' '�'J 7 � �/
NAME:
STATE LICENSE # LEAD CERT NLJM
ADDRESS: CITY
PHONE
FAX
QSINGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILY/NEW CONSTRUCTION STORIES Z
❑ ADDITION ❑ GARAGE/SHED ❑ W[NDOWS
❑ BASEMENT FINISH �I.ROOF ❑ DRAIN TILE
❑ DECK �SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
¢�'MAINTENANCE(REPAIR ❑ REMODELING
ROOFING (�
NUMBER OF SQtJARES I (
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING �
❑ Vi��y1
❑ Aluminum
�Othet L„�
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
� HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑So�t
f�'Trim
�Fascia
Permit No.: � 6 'CJ �'��
Received B�'
Da���'d) I.� L � �. � i� � �
�'d
�
WTDTH HEIGHT
LOCATION OF WINDOWS�
`� ,SS�� O
NUMBER OF
ATE,��ZIP �� y_3a
ATE ZIP,
F'I'
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDiNG DECKS,
ADD1T10NS. & PORCHES SUBMIT:
L Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WRJDOWS — 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)
COTAL 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 _
$ °�3'j-T�
$
$
$ J
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the totai 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 pavable to: Citv of Fridlev
Attach
THIS [S 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 of w h r Quires review and approval of plan . � � / /
SIGNATURE OF APPLICANT _� _ PRINT NAME �C�q�� ��aU'�_DATE �' `/ '�rG
APPROVAL iNSPECTOR SIG U