P - 39610Building
Inspections
763-572-3604
763-502-4977 FAX
DATE��i y/ / �
SITE ADDRESS �
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
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
r� S
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAlL ADDRESS ��� l�l
❑ OWNER RiCONTRACTOR
rr.a�t�: J D� u� lG ���'
.aDDRESS: �G� v'"�; � S,' s S
PHONE: 7 �r' � �,
NAME: M� O I,./ l�S 7�
STATE LICENSE #
�
ADDRESS: �j Cg vl...pt��' � �-1 _ �
�
�+,, �/'�
PHONE ���� " Z�^' G 6 u"G 6
� SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH ❑ ROOF
Q DECK !�1 SIDING
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
� MAINTENANCE/REPAIR ❑ REMODEL
_. T't�,Ii►r' 01 � In n, .' l� �� Ci , i/�►
SIDING
■ Vinyl �'�1�`�'� � Vt�1�l%��
❑ Aluminum
❑ Other
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
OSoffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
OF WINDOWS
Permit No.
Received By: �;���
Date R�' j� ��� � � �
C►TY �'�i � �� STATE�{�l� Z[P
LEAD CERT NUMBER �✓T�� �D,� CC��'f
�✓ CITY �'i��/a� �p(�TATF,/NdiZIP—���{
FAX
SIZE
STORIES
O WINDOWS
❑ DRAIN TILE
❑ OTHER
ti� ',� f/'. � y /
HEIGHT� SO FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION [NCLUDiNG DECKS,
ADD[TIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing s[ructures
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 $ C OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
i Park Fee
� Sewer Main Charge
! Total Due
$
$ � Z �►U
$ �? �
$ �i
$
$
$
$
$
$ •S
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 pavable 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 of all erk which requir s review and approval of plans. " � � /L >
SIGNATURE OF APPLICANT G� PRINT NAME T� '�^� 1� �QL� DATE ��Z T"/ /�
APPROVAL INSPECTOR SIGNATURE